Parent Form

Being that your daughter will be living with us, it is helpful for us to know about any significant family changes or events your daughter may have experienced in recent years. This information will be kept confidential. We request this information in order to better understand your daughter and her needs.

Name:  

 1. Have there been any significant changes or events in your family that may influence your   daughter's school emotion state?  
 If Yes, please specify and elaborate below
 Other/ please elaborate: 

2.  Has your daughter ever experienced any of the following problems? If yes, please specify  below.
      Specify Below:

3. Has your daughter ever received, or is she receiving, counseling/therapy or psychiatric treatment for any of the reason stated in questions 1 or 2?  If yes, please explain:

 4. In order to be able to support your daughter, if she is receiving counseling for an ongoing    issue that pertains to her social/ emotional needs, we require access to the counselor. We    do not expect any personal information to be revealed, only information that the counselor    deems necessary for us to know. 
 Name of counselor:   Phone Number: 

Please share with us an insights into your child that will help this to be a a successful year.

If you child is on any medication please be in touch with the dorm mother, Mrs. Chani Brook, so that she can arrange to receive a copy of the prescription to keep on file. This will be kept completely confidential, and does not need to be given to the school office. 

To the best of my knowledge, all of the above information is accurate. The dorm does not assume responsibility for any withheld information.  

Parent or Legal Signature:  Date: 
Parent or Legal Signature:  Date: