Ceres Unified School District Referral Form
Ceres Healthy Start
(209) 556-1559 / Fax: (209) 537-6209

Child Welfare and Attendance
(209) 556-1540 / Fax (209) 538-6214

Student Support Services
(209) 556-1533
School Site: *
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Referred By: *
Referred by (Name): *
Your answer
Phone Number: *
Your answer
Email:
Your answer
Request Type: *
Required
Insurance Status:
Your answer
Date: *
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DD
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YYYY
Student ID:
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Last Name: *
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First Name: *
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Date of Birth: *
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/
DD
/
YYYY
Age:
Your answer
Grade:
Does the student have siblings? If so, please list their name(s) and age(s) below:
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Has the parent been notified that they may be contacted: *
Reply Requested (for referring staff):
Parent/Guardian:
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Address:
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Primary Language: *
Will a Translator be needed for the initial meeting? *
Phone Number #1 *
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Phone Number #2
Your answer
Transitional Housing *
Reason for referral *
Your answer
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