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SUPPORT SERVICES REFERRAL FORM
***If this is an emergency regarding the safety of a student (which includes, but is not limited, to self harm, threats of self harm or physical aggression), STOP. Contact Support Staff, Administration or Security BEFORE completing this referral form.***
Your Email address
Student's Name
First
Last
Grade
6th
7th
8th
Person making Referral
First
Last
Have you contacted the parent/guardian regarding this concern?
Yes
No
Actions taken by the person referring this student (Check all that apply) *
Spoken with student
Spoken to parent/guardian
Emailed parent/guardian
Issued detention
Conference with other staff/administration
Completed BIF
other
Reason for referral (check all that apply) *
Academic Concerns
Absences
Peer Relationships
Personal Hygiene
Family Concerns
Dramatic change in behavior/emotions
Cries easily and/or often
Withdrawn
Sleeping in class
Grief due to a loss
Excessive nurse/health center visits
Anger
Social media issues
Physical or verbal aggression **Please contact security/admin/support staff ASAP
Hurts self or threatens to hurt self **Please contact (in person) any support staff/admin ASAP
other
Clarify referral problem/concerns
Level of Concern
Low (schedule when available)
High (Schedule as soon as possible)
Send me a copy of my responses.
Please select
Yes
No
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