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Helping Families Initiative Referral Form
The Lee County Helping Families Initiative is a program of the Lee County District Attorney's Office in partnership with the surrounding public schools.
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Student Name *
Today's Date *
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/
DD
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YYYY
Home Address *
Grade *
Name of School *
Student ID
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Area(s) of Concern: *
Required
Brief description and duration of problem(s):
Referral Name:
Clear selection
Referral Name & Phone # *
Parent(s)/Guardian(s) Name & Relationship to Student *
Parent(s)/Guardian(s) Phone Number *
Parent(s)/Guardian(s) Email
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