Referral for Intervention
1.When a student is in IMMEDIATE need or danger, please seek help from a social worker or Administrator IMMEDIATELY and do not leave the student unattended. Then complete this form as a follow-up.

2.Completing this referral does NOT release you of your mandated reporting responsibilities.  

3.Once a student is referred, someone from the Intervention Team will meet with the student to determine services.

Email *
Student name *
UID:
School Site *
Reason for Intervention *
Required
Other Information
Previous Tier II Interventions
Other possible concern(s) (can check more than one if applicable)
Other Information
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Kern High School District.

Does this form look suspicious? Report

Google Forms