Refer a Student/Request Information about Alternative to Suspension/TUPE Programs 24/25
Please use this form to refer a student and/or request information regarding substance use, alternative to suspension, and other support groups provided by the district. If you have any questions, please contact jcadigan@smuhsd.org.
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Student Name *
Student ID# *
School Site *
Grade Level *
Gender *
What age is the student? *
Student's Parent/Guardian Name *
Student's Parent/Guardian Email (Required for sending Consent Forms) *
Did you obtain verbal consent from this student's guardian? 
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Who did your receive consent from? 
Does parent/guardian need interpretation services?  If yes, in what language? *
Does the student need interpretation services? If yes, in what language? *
Please check if this student is Latino/a. We track this for our TUPE grant.
Is this a referral for a disciplinary incident? *
If disciplinary, how many days of suspension is this student receiving IN ADDITION to the ATS being requested? *
If disciplinary, how many days of suspension is this student AVOIDING due to the ATS being requested?
*
Referrer *
Referrer Name *
Referrer email *
Referrer Phone Number *
Please explain the incident and/or reason for referral *
From offered Alternative Programs listed, what is your current recommendation? (**Please note that our team of trained professionals will assess the student for appropriate program/service fit for student)
If this is a referral for having a vape, was it a nicotine vape or a cannabis vape, or did they have both?
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Anything else we need to know?
Submit
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