Student Support Services: Request for Assistance

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Please complete this request for assistance form below to initiate a referral regarding a concern about a student's academic, behavior, and/or mental health/social-emotional progress/functioning and how it may impact access to their education.

Please Note: Completing this form does NOT guarantee services, but will initiate a conversation by the Tier 2/3 team and school site admin to review and provide the most appropriate form of support for the student.

*** IF THIS IS AN URGENT REFERRAL, SUCH AS SUICIDAL THOUGHTS OR CONCERNS ABOUT SAFETY, please notify your administrator immediately and/or CALL 9-1-1 OR THE NATIONAL SUICIDE HOTLINE AT 1 (800) 273-8255 (TALK) IMMEDIATELY***

Email *

Record my email address with my response

Student Last Name *

Student First Name *

Student's Date of Birth *

YYYY

School Student Attends *

Grade Level *

Is the student in the Dual Language Immersion (DLI) Program? *

Yes

Who is Referring? *

Referring Person's Name: *

Referring Person's Phone Number *

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