Student referral form
Once Mrs. Cleveland receives this form, she will contact your teacher for the best time to pull you out of class for a meeting. If you don't hear from her within 2 school days, please email or call 509-558-3433.
Student name (first & last) *
Grade *
Teacher *
What do you want to talk to me about? *
What size of a problem do you think this is?
Clear selection
What is the best way to contact you about meeting? (please put email or phone number in the "other" category)
Clear selection
On a scale from one to five, right now you are feeling (see picture below): *
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