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Student Referral Form
*****This form is for use during the school year and is not monitored during the summer months****
If this is an emergency and you need to talk with someone right away, please call 911 or the crisis care line at 988.
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* Indicates required question
Do you want to refer a student or family for resources or support from the SSA?
The following 5 questions will help the SSA in following up with the student / family.
Students and families can also self refer with this form.
1. Name of person completing this form.
*
Your answer
2. What is the First name of the student in need of support?
*
Your answer
3. What is the Last name of the student in need of support?
*
Your answer
4. What support or resources do you believe the student / family needs? (please check all that apply)
*
Choose
Food (Thanksgiving Meal, Food Packs, Food Bank)
Housing Resources (Shelters, Long-term Housing, Rental Assistance)
Mental Health Resources and Therapists Referrals
Racial & Cultural Support (Students of Color Career Conference)
LGBTQ+ Support
Resources for paying bills
Clothing Resources (PE Clothes, Operation School Bell, Clothes for Kids, ect)
Legal Difficulties / Documentation (Birth Cert, ID, DACA, Social Security)
State and Federal Assistance (EBT, SNAP, WIC, ect.)
Holiday Help
CULTURE CLUB
Other Support or Resource
5. Can you please share any other details that you feel may be helpful to know about the student / family? (please include your name in case I have follow up questions)
*
Your answer
Click Here to Join Raylin's SSA Resources Parent Square Group
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