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Student Services Referral
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* Required
Email
*
Your email
Period
*
Period 0
Period 1
Period 2
Period 3
Period 4
Period 5
Period 6
Period 7
Other:
Student ID
Your answer
Student Last Name
*
Your answer
Student First Name
*
Your answer
Referring Staff Member's Name
*
Your answer
Student Grade
*
9th
10th
11th
12th
Student Behavior
*
Cell Phone Use
Defiance
Disrespect
Disruption
Dress Code
Harassment / Tease / Taunt
Profanity / Inappropriate Language
Physical Aggression
Property Misuse / Destruction / Vandalism
Stealing / Theft
Tech Violation
Other:
Required
Interventions Logged in Aeries Attempted by Teacher Prior to referral (Choose all that apply)
*
Proximity control
Redirection
Moved seats
Conversation with student
Call home
Emailed parent/guardian
Meeting with student and parent
Detention assigned
Class suspension
Other creative interventions
Required
Brief Description of the Incident
*
Your answer
Administrative Interventions: Conference with Student, Parent Contact, Parent/Teacher Meeting / SST / 504 / IEP, Case Manager / Counselor Referral, Detention, Class Suspension, School Suspension, Other
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