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Check and Connect Referral
The Pinon Project Check and Connect Student Advocacy Program
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Date
MM
/
DD
/
YYYY
Student Name
Your answer
What school does the student attend?
Your answer
Grade Level
Your answer
Referrer's Name
Your answer
Referrer's Email
Your answer
Referrer's Phone Number
Your answer
Parent's Name
Your answer
Parent's Phone Number
Your answer
Parent's Email
Your answer
Home Address
Your answer
List known siblings or other children within the home
Your answer
Check all that Apply
Poor Attendance
Disruptive Behavior
Incomplete Assignments
Poor Performance
Tardy
Disengagement
Other:
Average Grade
A
B
C
D
F
Parent's Involvement in Child's Education
High
Adequate
Low
Clear selection
Is the student receiving any additional services?
Tier Supports
Native American Liasion
Other:
List any other supports/interventions (academic or social) not listed above.
Your answer
List any outside agency involvement ie. social services, behavioral health, probation...
Your answer
Please add information based on your experience with the student and family.
Your answer
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