Community Kennett Intervention Team (KIT) Referral
If the student of concern is: expressing suicidal thoughts, making threatening comments to others, is suspected to be under the influence of drugs and/or alcohol, or you suspect abuse and/or neglect, call 911. Do not complete this form.
This form is checked on a weekly basis. If you need further assistance, please contact the KHS Counseling Office at (610) 644-6620.
Student Information (Please indicate any known identifiers including name, grade, age, etc.) *
Your answer
Area of Concern *
English/LA
Math
Science
Social Studies
Study Skills
Organization
Other
None
Academics
Substance Use/Abuse
Attention
Social Skills
Withdrawal
Other
None
Mental Health/Wellness
Vision / Hearing
Weight Loss/Weight Gain
Hygiene
Basic Needs / Living Essentials
Other
None
General Health
Tardy (School/Class)
Bullying (Aggressor/Victim)
Skipping Class
Full Day Absences
Noncompliance
Other
None
Code of Conduct
If "Other" selected above, please describe:
Your answer
Existing Supports *
Please indicate if the student receives any of the following, if known.
Required
Additional Comments
Please provide, in brief detail, any additional information necessary (including other areas of concern as well as any suggested interventions being requested).
Your answer
Would you like this referral to be anonymous? *
Required
If No, please provide your name, relationship to the student, phone number and email address.
Your answer
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