JSHS Referral Form
* Required
Last name, First name
*
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Grade
*
Senior - 12
Junior - 11
Sophomore - 10
Freshman - 9
8th
7th
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My problem is...
*
Check as many as you need.
worried about school
worried about home
having trouble with another kid
having trouble with an adult
trying to do better but it's hard
confused
missing someone
can't concentrate
having a problem that is not on the list
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I need to see you...
*
RIGHT AWAY = BIG problem!
RIGHT AWAY!
Sometime today
Sometime this week
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