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South Ranchito Check N Connect Referral Form
**URGENT / CRISIS / DANGER TO SELF OR OTHERS MUST BE REPORTED TO AN ADMINISTRATOR IMMEDIATELY**
Email address *
Teacher / Staff name: *
Your answer
Date of Referral *
MM
/
DD
/
YYYY
Name of Student *
Your answer
Grade: *
Your answer
Services *
Required
Has the family been informed of your concerns? *
If the family has been informed, what type of contact has been made? *
Your answer
Please describe your primary concern about this student:
Your answer
Please check the appropriate box/s below: *
Required
**If "Other" is chosen, please describe:
Your answer
Please describe this student's strengths or recent accomplishments: *
Your answer
If you are aware that this student's family is facing difficulties, please describe below:
Your answer
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