Referral Form-Attendance Council
PLEASE GO OVER THE PARENT INFO & CONSENT FORM WITH THE YOUTH AND FAMILY FIRST.  AND THEN REFER THE CASE TO US VIA THIS PORTAL. We can accept verbal or written consent.

 *Red Asterisks indicate required information, all other information is helpful and optional.

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PLEASE GO OVER THE PARENT INFO & CONSENT FORM WITH THE YOUTH AND FAMILY FIRST. AND THEN REFER THE CASE TO US VIA THIS PORTAL. Did you get verbal or written consent from the parent/guardian and youth already? *
Today's Date *
Referral Is From Which School? *
Student First Name *
Student Last Name *
Student Age *
Student's Cell Phone
Name of Primary Adult *
Relationship of Primary Adult to Student (mom, grandfather, etc)
Primary Adult Contact's Phone Number. Please include as many phone numbers as possible. Cell, home, work, other *
Primary Adult's Email Address *
Name of Secondary Adult
Relationship of Secondary Adult to Student
Secondary Adult Contact's Phone Number
Student's Email Address *
Mailing Street Address *
City
Zip
Primary Language spoken at home, if not English?
Is an interpreter needed for this parent/guardian or youth? *
School Counselor/Point Person for this student referral *
Interventions already supervised by the school (check any that apply):
Brief narrative of attendance challenges that led to this referral (Concerns are mainly Cuts? Tardies? Excused absences? Other?). Include student's strengths and challenges : *
Copy and paste the attendance narrative from A2A for this student. *
Please give us their most recent quarter GPA and any further grades notes *
Anything Else to Add?
Submit
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