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Section 1 of 4
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K
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School District Faculty Member/Staff Member/Administrator
Parent
Community Member
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Section 2 of 4
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Yes
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Phone Call
Personal Meeting
Email
Letter/Notes home
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Section 3 of 4
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Section 4 of 4
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Academic Concern
Attendance (School Day)
Behavioral Concern
Bullied by others
Bulling by perpetrator
Continuation of case from another SAP team
Family Concern
Gambling
Homelessness
Involvement in Legal system
Military Connectiveness
Parent incarcaration
Runaway
Self-harm, injury (follow-up to crisis plan)
Skipping class
Suffered a recent loss
Suicide Ideation/Gesture/Attempt (follow-up to a crisis plan)
Suspected Child Abuse/Neglect
Suspected Drug and Alcohol Concerns
Teen Pregnancy
Tobacco Violation or self-reported tobacco use
Transient living conditons
Unexplained drop in grades
Violated school policy (Drug and Alcohol)
Violated school policy (violence/weapons)
Violated school policy (other)
Witnessed/Victim of traumatic event
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Name of person making referral
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Last name of student being referred
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First name of student being referred
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Grade of student being referred
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What is your role?
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Parent Contact (Recommended)
Have you contacted the parent of the student you are referring?
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What type of contact have you made?
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Tell us more about the contact you made and the results of that contact.
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Do you wish to continue with the referral process?
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Process Ended
End Process
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Referral Information
Reason for referral
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Additional Information
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Known Services or Interventions
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