BSMS YSC Parent Referral Form

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Do you have a concern about your student? Do you have an issue in the household you need assistance with? Do you need help, but don't' know the best way or where to start? Use this referral form and the Youth Service Center will direct your needs to the appropriate school staff or community organization for support. All information is confidential.

KRS 620.030(1) - Anyone with a reasonable suspicion that a child is dependent, abused, or neglected is required to make a report to the Cabinet for Health and Family Service (CHFS) https://prd.webapps.chfs.ky.goc/reportabuse/home.aspx

Email *

What is your (parent/guardian) first and last name? *

Best phone number to reach you? *

What is your student's first and last name? *

What grade is your student in? *

If your reason for contacting us due to academic concerns? *

Attendance related

Academic performance (not turning in work, failing quizzes/test, etc.)

Academic skills (time management, study skills, test-taking skills, etc.)

Other academic coners

No academic concerns.

If your reason for contacting us due to personal issues? *

Medical/mental health issues

Social connections (problems making friends, doesn't fit in, etc.)

Lack of food/necessities

Other personal issues

No personal issues

If your reason for contacting us due to financial issues? *

Assistance with job placement/opportunities

Assistance with home bills (electric, heat, etc.)

Other financial issues

No financial issues

Briefly tell us more information regarding your reason for contacting us. *

Would you like a follow-up contact from the BSMS Youth Service Center staff? *

Yes

Send me a copy of my responses.

Submit

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