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Parent/Caregiver Virtual Referral
Thank you for reaching out so I can help support your student.
IF THIS IS AN EMERGENCY and your child or a child you know is in immediate danger to themselves or others call 911 or take them to the emergency room immediately. If you are worried about the safety or possible abuse of a child contact our local Department of Social Services at 410-713-3900 or click this link below for Wicomico County Dept. of Social Service website:
http://www.chamberdata.net/webforms/wicomico-county-dept-of-social%20services__1_685_5007861_memberprofile.aspx?dbid2=mdsal
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Grade level of child/children:
*
9th grade
10th grade
11th grade
12th grade
Required
Teacher Name
*
Your answer
Student Name
*
Your answer
Names of siblings?
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Your answer
Your Name
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Your answer
Best Phone Number (please enter (xxx) xxx-xxxx) *
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Your answer
What are your concerns?
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Safety?Abuse
Access to Technology
Access to outreach supports- food, clothing, etc.
My child/children need support
Other:
I need help
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Finding a therapist for my child
Getting my student motivated to work form home
Finding resources for food, clothing, etc.
Getting ideas and suggestions on how to support my child
Getting ideas and suggestions on how to support my child's behavior at home
Other:
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