Redland Elementary FACT Referral Form

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Please use this form to refer any students to the FACT Program. The case worker for your school will receive the responses and will follow up in a timely manner. If you have any questions, please contact Redland's case worker Michelle Rigby at (334)224-1868 Ext. 704 or Michellerigby@ecfrc.org.

Email *

Date *

YYYY

Who is making this referral? *

Teacher

Admin

Support Staff

Teacher's Name *

Teacher's Email *

Student's Name *

Student's Birthdate

YYYY

Grade *

3rd

Kindergarten

4th

1st

2nd

Student Gender *

Male

Female

Prefer not to say

Other:

Student Race/Ethnicity *

Black

White

Hispanic/Latino

Indigenous or Native American/Alaskan

Asian

Pacific Islander

Multiracial

Unknown

Other:

Parent or Guardian's Name *

Parent/Guardian's Phone Number *

Parent/Guardian's Address *

Reason for referral *

Have you already contacted administration about this situation? *

Yes

Other:

What is the best time to pull student from class? *

A copy of your responses will be emailed to the address you provided.

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