Sandy Valley Middle & High School's 2018-19 CARE Team Student Referral Form
Please fill in the statements below to refer a student to our CARE Team. Your insight will be helpful as we develop the best strategies/interventions to help this student thrive in our school building.
Student First Name *
Your answer
Student Last Name *
Your answer
Please Offer Additional Student Information:
Grade *
Age of Student
Your answer
Ethnicity *
Zip Code of Student
Your answer
Parent/Guardian Name *
Your answer
Referral Submitted By *
Your answer
Prior Contact Has Been Made With Family Regarding This Referral *
Please check AS MANY BOXES below pertaining to the referred student:
Please check any concern(s) that may apply to your student
Abuse or Neglect Suspected
Academic Concern
Attendance Concern
Behaviors Needing Office Referrals
Death of Family Member or Caregiver
Domestic Violence Concern
Family Support Needed
Hygiene Concern
Incarcerated Family Member or Caregiver
In Foster Care
On Probation
Social, Emotional, or Peer Concern
Please provide a short narrative about your over-all concerns for this student: *
Your answer
Protective Factors & Resiliencies are positive supports, strengths, attributes a student has ~ with these thoughts in mind, please respond to the 2 statements below:
What protective factors/resiliencies do you think this student has? *
Your answer
What protective factors/resiliency skills do you think needs to be built with this student? *
Your answer
Student is Being Referred to Our CARE Team *
Thank you for taking the time to send this referral to our CARE Team. Please hit the submit button to complete this process.
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