Student Support Plan Form - Virginia
Student Support PlanStudents have unique needs regarding affirmation of their gender identity. At a student’s request, school personnel should work together with the student to develop a plan that meets the student’s needs. A sample student support plan is provided on the next page to guide school teams in addressing the various aspects of a transgender, non-binary, or gender-expansive student’s needs and well-being. Considerations for local school divisions in developing a support plan template include:What is the division’s policy regarding instances where the parents/guardians are not affirming of the student’s gender identity? Is parent/guardian consent or participation required to develop a support plan? If so, under what conditions (e.g., certain ages of students) would parent/guardian consent be required?What are the division’s policies and regulations that would inform each element of a support plan? Are there other policies and regulations that need to be included or referenced (e.g., bullying/harassment or records)?How will the student’s privacy be maintained? Where will the support plan be kept? Will the plan transfer with the student?How will information from the support plan be communicated to the appropriate staff?Sample FormThe purpose of this document is to create shared understanding about the ways in which the student’s gender identity will be accounted for and supported at school. School staff, families, and the student should work together to complete this document. At the student’s discretion, parent/guardian participation in developing a support plan is not required (if this is in accordance with local policy). This plan contains confidential information and will only be shared with staff on a need-to-know basis with input from the student and parent/guardian. It will not be kept as part of the student’s cumulative records but rather maintained in a confidential location with student services or with the administrator. These records will transfer with the student such as from elementary to middle and middle to high school. If a student or parent/guardian does not wish for the shared understandings to be formally documented, the questions in the student support plan may be used only to guide the discussion.Meeting InformationMeeting Date: FORMTEXT ????? ?Student’s ID: FORMTEXT ????? ?Student’s Preferred Name: FORMTEXT ????? ?Meeting Participants: FORMTEXT ????? ?School Contact Person (e.g., case manager): FORMTEXT ????? ?Parent/Guardian/Family Involvement and SupportParent/Guardian Name(s): FORMTEXT ????? ?Are Parents/Guardians aware of student’s gender identity?Yes FORMCHECKBOX No FORMCHECKBOX Are Parents/Guardians affirming of student’s gender identity?Yes FORMCHECKBOX No FORMCHECKBOX Unsure FORMCHECKBOX Describe any support or resources needed for the family regarding the student’s gender identity or transition: FORMTEXT ????? ?Student Well-BeingDescribe student’s strengths: FORMTEXT ?????Describe any barriers or safety concerns and how to address them: FORMTEXT ?????List/enlist any allies (peers and adults) in the school and describe how they may support the student: FORMTEXT ?????What support does the student need from the school counselor/psychologist/social worker? FORMTEXT ?????What other resources, including community resources, would benefit the student? FORMTEXT ?????Confidentiality, Privacy, and DisclosureUsing input from the student and the parent/guardian (if applicable), discuss the following:How public or private will information about the student’s gender identity be?Division-level staff will be aware (Superintendent, Director of Student Services, etc.):Yes FORMCHECKBOX No FORMCHECKBOX If yes, specify who may know: FORMTEXT ?????School Leadership will be aware (Principal, Assistant Principal, School Counselor, etc.):Yes FORMCHECKBOX No FORMCHECKBOX If yes, specify who may know: FORMTEXT ?????Teachers and/or other school staff will be aware:Yes FORMCHECKBOX No FORMCHECKBOX If yes, specify the adult staff members who may know: FORMTEXT ?????Student is open with others (adults and peers) about their gender:Yes FORMCHECKBOX No FORMCHECKBOX Describe what information the student wishes to convey regarding their gender identity: FORMTEXT ?????Describe how the student wishes the information to be shared, including when, by whom, and with whom (e.g., classroom lesson plan, communication plan with other families, etc.): FORMTEXT ?????Describe any additional privacy/disclosure situations and needs, including any specific dynamics with other students or staff members: FORMTEXT ?????Names, Pronouns, Student RecordsIs a Request for Name and/or Gender Change being submitted?Yes FORMCHECKBOX No FORMCHECKBOX Preferred Name: FORMTEXT ?????Gender: Male FORMCHECKBOX Female FORMCHECKBOX Non-Binary FORMCHECKBOX Not Specified FORMCHECKBOX Other: FORMTEXT ????? ?Preferred Pronouns: FORMTEXT ?????If name and gender are not being updated in the student information system, describe specific situations and contexts in which the preferred name and pronouns will be used and how they will be communicated and reflected in documentation: FORMTEXT ?????If parents/guardians are not aware or affirming of the student’s gender identity, describe how school-home communication will be handled: FORMTEXT ????? Access to Activities and FacilitiesPlease note that students should be provided the option to use the facilities that they feel best align with their gender identity.Student will use the following restroom(s): FORMTEXT ?????Describe plans or options for the student’s choice as to where to change clothing: FORMTEXT ?????What are the expectations of the student regarding the use of facilities for any field trips? FORMTEXT ?????What are expectations of the student regarding rooming for overnight field trips? FORMTEXT ?????Describe any additional considerations regarding the student’s access to facilities: FORMTEXT ?????Will the student access any programs, activities, or events that are sex-segregated? If so, please note those here: FORMTEXT ?????Describe any additional considerations regarding the student’s access to programs, activities, and events: FORMTEXT ?????Support Plan ReviewDescribe any specific action items or follow-ups as a result of this meeting, including who is responsible and timeline for completing them: FORMTEXT ?????Describe any process for monitoring and/or revising the support plan over time: FORMTEXT ????? Date/Time of next meeting: FORMTEXT ?????ReferencesDistrict of Columbia Public Schools Transgender and Gender-Nonconforming Policy GuidanceGender Spectrum Gender Support Plan Gender Spectrum Gender Communication Plan Montgomery County Public Schools Intake Form: Supporting Student Gender IdentityPortland Public Schools Gender Diversity Support Plan ................
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