Student's Parent/Guardian Email (Required for sending Consent Forms) *
Your answer
Did you obtain verbal consent from this student's guardian?
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Who did your receive consent from?
Your answer
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 *
Your answer
Referrer email *
Your answer
Referrer Phone Number *
Your answer
Please explain the incident and/or reason for referral *
Your answer
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)
Choose
Not sure - we will email you (referring party) to consult on best fit
Vaping Awareness Prevention & Education (VAPE) group - nicotine use
Substance Use Program (SUP) group - all other substance use
Brief Intervention (BI) for substance use - one-on-one substance use intervention
ATS group - Dehumanizing Language: contact Amelia Nash anash@smuhsd.org with questions
Alternative to Suspension (ATS) group - all other incidents besides substance use
Flex - Alternative to Suspension (ATS) group or individual - during Flex time
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?
Your answer
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This form was created inside of San Mateo Union High School District.