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School / Community Partner Referral Form
Educators and community partners seeking to support a student with educational needs are welcome to call (734-482-0489) or email (
helpline@studentadvoacycenter.org
) our Helpline for support. You can share the Helpline information with a caregiver / student or you can directly refer a student here.
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* Indicates required question
Your Name
Your answer
School and District or Community Agency
Your answer
Would you like your referral to remain confidential from the school / district / agency?
Yes
No
Clear selection
Your Email
Your answer
Your Phone Number
Your answer
Reason for Referral (Check any that apply)
*
Student is facing expulsion or long-term suspension
Student has been suspended 10 or more days (does not have to be cumulative)
Student WAS expelled and needs help with reinstatement / reentry
Student has a MDR meeting coming up
Student is failing and has a suspected disability
Student has been denied special education services or accommodations and continuing to struggle in school (grades, attendance and/or behavior).
Student has missed 10 or more days of school and is facing barriers to regular attendance such as mental illness, chronic illness, homelessness.
Student is failing classes and needs help navigating the personal curriculum process.
Student has stopped attending / dropped out and needs a plan to return to school.
Other:
Required
Student Advocacy Center invests in students groups that have historically been underserved or face unique barriers to school. Please check any that apply.
In a temporary living situation / homeless
Unaccompanied youth
Experiencing foster care
Involved with Child Protective Services
Has a recognized or suspected disability
Has a caregiver with a recognized or suspected disability
Involved with the Juvenile Justice or criminal justice system
Adopted
Name of Caregiver
Your answer
Caregiver Email
Your answer
Caregiver Phone Number
Your answer
Name of Student
Your answer
Student Email
Your answer
Student Phone Number
Your answer
Is the family expecting our call?
Yes
No
Unsure
Clear selection
Anything else we should know?
Your answer
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