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Student Support Services Referral
RE-1 Valley Schools Student Support Services Team is available to support students through direct services, consultation with staff and families, and through collaborative efforts with community resources. Please contact your building student support services staff if you have had no response in 48 hours.

ANY AND ALL SAFETY CONCERNS (SUSPECTED CHILD ABUSE, SUICIDAL IDEATION/BEHAVIOR AND/OR THREATS TO OTHERS) SHOULD BE IMMEDIATELY DIRECTED TO YOUR BUILDING ADMINISTRATOR OR 911

Student Last Name
Your answer
Student First Name
Your answer
School student is attending
Grade Level of Student
Your Name (referral source)
Your answer
Your role with student
Your e-mail address (if not RE-1 staff)
Your answer
Your phone number
Your answer
Concerns at School
Required
Concerns at Home
Required
Concerns with Behavior
Required
Concerns with Friends
Required
Concerns with Health
Required
Concerns with Mental Health
Required
Comments/additional details
Your answer
Has a parent been contacted?
Please provide a brief summary of the contact with, or attempts to contact, the parent(s):
Your answer
Please provide a brief summary of your concerns and/or efforts regarding this student:
Your answer
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