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Request For Assistance
Parents, do you have concerns about your child?

**If this is an emergency, please contact the school directly, or 911.

Staff, do you have academic, social or behavioral concerns about a student?

This is a fast and easy form and will come directly to the Intermediate staff.

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Email *
Student Name *
Grade: *
Who have you contacted about this concern?

**Family contact prior to RFA submission is expected**
 *
Required
FOR SCHOOL/FACULTY ONLY- Please provide dates of contact with parent/guardian, as well as method of communication (text, email, phone call, interpreter support, etc.) - parents/guardians MUST be notified that a RFA was filled out: *
Name of Person Referring Student *
Please list several strengths, talents, motivators, and/or special interests for this student: *
Reason(s) for Referral: Please describe presenting concern & how long it has been going on. Please give as much detail as possible: *
Check previous interventions:
Academic Concerns (check all that apply):
Behavioral/Emotional Concerns (check all that apply):
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