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ESD 113 Education Advocate Referral
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* Indicates required question
Email
*
Your email
Name of person submitting referral:
*
Your answer
Relation to student:
*
Your answer
Probation Counselor name (N/A if it does not apply):
*
Your answer
Probation end date:
MM
/
DD
/
YYYY
Student name:
*
Your answer
Student date of birth:
*
MM
/
DD
/
YYYY
Best phone number to reach youth:
*
Your answer
Most recent address in which youth resides:
*
Your answer
Names of parent(s)
/guardian(s):
Your answer
Email address:
Your answer
Phone number:
Your answer
If youth is/was enrolled in school, please provide the most recent school information:
*
Enrolled in Community School
Enrolled in G.E.D. Program
Gained High School Diploma
Gained G.E.D.
Is not engaged with any school
If enrolled, name of school or program (N/A if it does not apply):
*
Your answer
Primary language spoken in the home:
*
Your answer
Does student have:
*
IEP
504
N/A
Required
Please check all that apply for academic concerns:
*
Low state test score
Falling behind in credits
Majority of work not being turned in or on time
Other
Required
If answer is Other, please explain:
Your answer
Please check for any general school concerns (check all that applies)
Frequent abscences
Disruptive in classroom
Multiple Suspensions
Expulsion
Isolated from peers
Other:
Please check for any other social/behavioral concerns
Basic needs* (e.g. housing, food, safety, access to healthcare, etc. specify below)
Patterns of being picked on or bullied
Reports of feeling unsafe at school
Uncontrolled behavior
Criminal activity
Being a victim of violence
Suicide threats/self-mutilation
Family history (e.g. violence, family court involvement, incarcerated family member, substance use, health concerns, etc. Specify below))
If basic needs selected, explain below:
Your answer
If family history selected, explain below:
Your answer
Please provide any additional concerns or pertinent information regarding this student's behavior:
Your answer
Send me a copy of my responses.
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