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2023 - 2024 AEMS COST referral (STAFF ONLY)
Use this form to refer students and families for:
- Basic needs assistance
- Social/Emotional and Mental Health issues
- Non-urgent health needs
- Chronic academic, attendance and/or behavior concerns
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* Indicates required question
Email
*
Your email
Name of person making the referral
*
Your answer
Student's name
*
Your answer
Student's Grade
*
Choose
7th
8th
Date of last phone call you made to the family
MM
/
DD
/
YYYY
If you did not make a phone call within the last 2 weeks, please explain:
Your answer
Type of concern
*
Academic
Behavior referral
Access to technology
Basic needs
Socio/emotional/mental health
General health
Other:
Required
Please describe the concern in detail, including family's awareness of your referral
*
Your answer
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