EYMS SNAP Online Referral Form
Thank you for taking the time to express your care and concern about the students here at Eastern York Middle School.

Please use the form below to provide information about the student of concern. Please don't forget to click the submit button to ensure that we receive your responses. Unless you would like to speak with a member of the SNAP team, your identity will remain anonymous.
Student Name *
Your answer
Student's grade level *
Is that child in immediate danger? *
Please indicated the reason(s) for referral by checking any and all of the appropriate observable behaviors
Academic Performance
School Attendance
Physical Observations
Disruptive Behaviors
Atypical Behaviors
(Please remember to report ONLY observable behaviors, not opinions)
Your answer
Would you like to speak with a member of the SNAP Team?
What is your name? (You only need to enter your name if you would like to speak to a SAP Team Member. Your name and your referral will be kept confidential.)
(Last Name, First Name) Example: Jones, Sally
Your answer
What is your relation to the student being referred? *
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