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Care Team Referral Form
This form begins the process of referral to East Guernsey's Care Team to connect students and families to resources within and around our school community. Someone from the team will respond to the request within 3 school days of the referral being submitted. Thank you for your advocacy.
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* Indicates required question
Email
*
Your email
Student Name:
*
Your answer
Grade:
*
Your answer
Who is referring this student?
*
Your answer
Area(s) of Concern related to Student:
*
Attendance
Emotional Functioning (withdrawal, tearfulness, anger, agitation, frustration, etc)
Social Functioning (peer relationships, bullying, etc)
Physical Functioning (overly fatigued, hunger, weight loss/ gain, unkempt, etc)
Academic Functioning (unanticipated change of grades or academic habits)
Behavior (i.e. physical aggression, defiance, self-injurious behaviors, etc.)
Other (see Comment. below)
Required
Area(s) of Concern related to Family/ Home Life:
*
Loss of family member
Illness of family member
Loss of employment within family
Loss of housing
Food
Other (see Comments, below)
Required
Comments (Please specify above area(s) of concern):
*
Your answer
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