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PSA Referral Form
Kristal Rosas, Pupil Services and Attendance Counselor,
Student Support Service Center, Extension: 5435
Email:
kristal.rosas@lausd.net
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* Indicates required question
Email
*
Your email
Student´s First Name
Your answer
Student´s Last Name
*
Your answer
Teacher´s Name
Your answer
Room
Your answer
Period
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Grade
6
7
8
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Reason for referral (Select all that apply)
Excessive Absences
Case Management needs (ie. Homeless, Pregnant, parenting etc)
Classroom concerns (Tardiness, Absences)
Other:
Previous Interventions attempted (Select all that apply)
Parent Contact (Phone call made, parent, conference)
Student Conference
Letter sent home
Other:
Please write any additional, concerns, or comments
Your answer
A copy of your responses will be emailed to the address you provided.
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