Student Support Services Referral 17-18
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
Comments
Your answer
Concerns at Home *
Required
Comments:
Your answer
Concerns with Behavior *
Required
Comments
Your answer
Concerns with Friends *
Required
Comments
Your answer
Concerns with Health *
Required
Comments
Your answer
Concerns with Emotional Function *
Required
Comments
Your answer
Has a parent been contacted? *
Required
Please provide a brief summary of the contact with, or attempts to contact, the parent(s):
Your answer
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