STUDENT SUPPORT TEAM (SST) REFERRAL Student (Self) Form
Student Name *
Your answer
Grade *
Your answer
Student ID # *
Your answer
Date *
MM
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DD
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YYYY
Contact Information
Parent/Guardian Name *
Your answer
Parent Phone Numbers
Your answer
My Concerns (In your own words describe what help you need.) *
Your answer
Do your parents know about your concerns? *
Language Spoken at Home
Teacher(s) *
Your answer
Have you talked with your teacher or counselor about this concern? *
If yes, who?
Your answer
What was the outcome?
Your answer
Where do you need the help? (Check all that apply) *
What has been done so far to help you? (Put a check next to things that helped.)
Your answer
Your answer
Your answer
Your answer
Your answer
My Strengths *
Required
I have difficulty: (Check all that apply)
I need help to stop doing: (Check all that apply) *
Required
Other Comments/Concerns
Your answer
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