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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:
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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:
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Please check the appropriate box/s below:
Required
**If "Other" is chosen, please describe:
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Please describe this student's strengths or recent accomplishments:
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If you are aware that this student's family is facing difficulties, please describe below:
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