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Alliance MIT Referral Form
Upon filling this out, the student will be contacted by an Alliance MIT counselor or administrator in order to assist in meeting the needs mentioned below.
Al completar este formulario, un consejero/a o administrador de Alliance MIT se comunicará con el estudiante para ayudarlo/a con la necesidad que ha expresado en este formulario.
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* Indicates required question
Your Name/ Su nombre
*
Your answer
Student Name/ Nombre del estudiante
*
Your answer
Student Grade
*
Choose
6
7
8
9
10
11
12
Reason for referral/ Razón de la referencia
*
Need basic support (food, water, shelter, medical care, supplies)/ Necesita apoyo básico (comida, agua, refugio, atención médica, suministros)
Academic Concerns/ Preocupaciones académicas
College Counseling/ Consejería universitaria
Cyberbullying
Stress/ Estrés
Anxiety, Worry, Fear/ Ansiedad, preocupación, miedo
Anger/ Ira
Agression towards others/ Agresión hacia otros
Self harm/ Autolesiones
Loneliness, isolation/ Soledad, aislamiento
Family relationship issues/ Problemas de relación familiar
Other/ Algo diferente
Other:
Required
Any details that would help us refer to the right person... / Por favor mencione cualquier detalle que nos puede ayudar referir el estudiante a la persona adecuada ...
Your answer
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