2024-2025 School Social Worker/FRC Referral
This form is to be utilized to request assistance from School Social Worker/FRC.  Please make sure that the parent/caregiver is aware that a district social worker will be contacting them for the purpose of gathering information, providing support and resource linkage.  
Sign in to Google to save your progress. Learn more
Email *
Your name: *
Your Phone Number: *
School *
Required
Student's Name: *
Student's Grade: *
Parent / Guardian's Name *
Primary language spoken at home *
Street Address, City, State, Zip
Parent/Caregiver Email Address or Student Email Address (if self-referral) *
Parent/Caregiver Telephone Number: *
Presenting Problem (CHOOSE ONLY ONE- if there are multiple needs specify in next question): *
Required
Please describe the problem in detail:

 *
Have you made the family aware that a School Social Worker referral has been made? *
If you have any additional questions or comments, you may request contact or contact the assigned School Social Worker that serves your school.
Hayden Curtis  LCHS, LHS, LES, & SLES  931-300-3238
hayden.curtis@lcss.us
Katie Reed    ISES, LPS, SES, & SHS/SMS  931-300-3964 
katherine.reed@lcss.us
Kate Perry-Oflaz  EOC, NPES, DCES, & EES  931-300-3240 mkate.perryoflaz@lcss.us
                                                                                        
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Lawrence County Schools.

Does this form look suspicious? Report

Google Forms