Staff Support Request

Name of Employee

Employee ID

Campus CampusAbilene High SchoolATEMS @ The LIFTCooper High SchoolHolland High SchoolWoodson Center for ExcellenceClack Middle SchoolCraig Middle SchoolMadison Middle SchoolMann Middle SchoolAlcorta ElementaryAustin ElementaryBassetti ElementaryBonham ElementaryBowie ElementaryDyess ElementaryMartinez ElementaryOrtiz ElementaryPurcell ElementaryStafford ElementaryTaylor ElementaryThomas ElementaryWard ElementaryCenter for InnovationEarly Childhood ProgramsFacilitiesOne AISDTransportationWarehouse

Anonymous AnonymousYes, make my information anonymousNo, contact me if needed

Your Name

Your Email Address

Relationship to Employee Relationship to EmployeeTeacher / Faculty MemberParent / RelativeFriend / Peer

Physical Health Physical Health Illness Lack of Sleep Signs of Abuse Inability to Perform Required Task

Mental Health Mental Health Thoughts / Threats of Suicide Needs Encouragement Relationship Troubles Depression Stress Anxiety

Life Management Issues Life Management Issues Crisis at Home Loss of a Family Member Loss of a Friend Financial Trouble

Behavioral Issues Behavioral Issues Inappropriate Behavior Disruptive Behavior Verbal Harassment Physical Harassment

Other Other Other - please explain

Please describe discussions or contact you have already had with the staff member

Please write any additional information about this situation that you think would be helpful for our office to know