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Intervention Request Form (Formulario para solicitud de intervención)
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* Indicates required question
Student's First and Last Name (nombre de estudiante-primer, apellido):
*
Your answer
Student's 6-digit UID (número de estudiante):
Your answer
Student's Grade (grado del estudiante):
*
9th
10th
11th
12th
12+
Counselor (consejera):
*
lorenzo_moran@kernhigh.org
gladys_sepulveda@kernhigh.org
esther_serrato@kernhigh.org
miryam_flores@kernhigh.org
salvador_gochez@kernhigh.org
brooke_malleyault@kernhigh.org
larissa_salinas@kernhigh.org
cynthia_valdez@kernhigh.org
Reason for Concern (motivo de preocupación):
*
Aggression (agresión)
Behind in Credits (deficiente en creditos)
Chronic Absences (ausencia crónica)
Death in Family (fallecimiento en la familia)
Defiance (desafío)
Lack of Motivation (falta de motivación)
Mental Health Concerns (preocupación por la salud mental)
Substance Abuse (abuso de sustancias)
Tardies (tardanza)
Other (otro)
Required
Additional Information (información adicional):
*
Your answer
Your Name (tu nombre):
*
Your answer
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