Communities In Schools (CIS) Referral Form - SMS
Please do not use this form in the event of an emergency. If child abuse is suspected, the student is expressing suicidal ideations, or the student is a danger to themselves or others, please follow the appropriate intervention plan(s) put in place by the school or local law enforcement, notifying applicable agencies such as DSS and/or local law enforcement.
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STUDENT INFORMATION
Name *
Grade *
Homeroom Teacher *
YOUR INFORMATION
Name *
Relationship to Student *
Date *
MM
/
DD
/
YYYY
Best Time to Contact You *
Email Address *
Phone Number *
REFERRAL INFORMATION
Is student aware of referral? *
Is parent/guardian aware of referral? *
If no, why not?
Why are you referring the student to CIS?
Please check all areas of concern and provide any additional information so that we can best understand the student's needs.
Please check all that apply.
Parenting Teen
Issues at Home
Difficulties with Peers
Limited Parental Involvement
Poor Hygiene
Suspected Drug Abuse
Suspected Mental Health Concerns
Homeless
Lack of Basic Needs (Food, Clothing, Health Services)
Recent Change of School/Home
Suspected Gang Affiliation
Poor Academic Achievement
Poor Attendance
Disengagement/Lack of Motivation
Disruptive Behavior
Excessive After School Work Hours
Learning Disability
Other
Please include any other pertinent information, particularly if you checked "Other" above.
CURRENT SERVICES
What interventions have been tried with the student? *
What other supports is the student receiving? *
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