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2023-2024 AEMS Family/Caregiver referral
Use this form if:
- You would like to schedule a check-in meeting with a counselor for your student
- Your family is in need of help or resources and would like to speak to counselor
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* Indicates required question
Email
*
Your email
Is this referral for yourself or someone else?
*
Choose
My student or family
Another Student
Student's name
*
Your answer
Name of person making the referral
*
Your answer
Student's Grade
*
Choose
7th
8th
What is the best way to get in touch with you? Enter your number or email:
Your answer
Have you had contact with a teacher or staff at Sam Brannan? If yes, who
Your answer
Type of concern
*
Grades or school work
Having trouble with technology
Food, clothing, housing
Mental health
General health
Other:
Required
How soon do you need to speak to someone?
*
It can wait a couple of days
1
2
3
4
5
It's very urgent
Submit
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