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Alt. Ed Staff Counseling Referral
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* Indicates required question
Email
*
Your email
Student Name
*
Your answer
Program:
*
FVHS
AFC
CAL
OAKDALE
Required
Name of person initiating counseling referral:
*
Your answer
Confidential
*
Yes
No
Required
Reason for referral (please be specific):
*
Your answer
Student Strengths
*
Your answer
Please rate the level of severity from 1-10
*
Mild adjustment problems (e.g. known home stressor, irritable; friendship difficulties)
1
2
3
4
5
6
7
8
9
10
Severe Issues ( e.g. aggression; hurting self and/or others; property damage)
Would you like to be notified of the outcome of the referral?
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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