Family School Liaison Referral Form
Please Use this form to request assistance from our Family School Liaisons or Student Support Coordinator when a member of your household is in need of wraparound/community support. These requests will be handled based on order received and need. If you have other questions please feel free to reach out to us directly:
Allison Scott: Student Support Coordinator: allison.scott@raypec.org
Alicia Gedwillo: Family School Liaison: alicia.gedwillo@raypec.org
Addison Schultz: Family School Liaison: addison.schultz@raypec.org
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Email *
Parent/Guardian Name *
Student(s) Name(s) *
School(s) your student(s) attends (check all that apply) *
Required
Contact Information: Phone number *
Contact Information: Email *
Number of individuals in your household
Are you currently receiving any services? If yes, which ones?
Are you or anyone in your household in current need of any of the following resources? Please check all that apply.  
Do you have any of the following concerns regarding behavioral/development for the child(ren) living in your household? Please check all that apply.
Are you or anyone in your household in need of any of the following mental health services, referrals, or consults? Please check all that apply.
Are you or anyone in your household in need of any of the following health services, referrals, or consults? Please check all that apply.
Are you or anyone in your household in need of any of the following services, referrals, or consults? Please check all that apply.
Please note: We work school hours. We will get to these requests as soon as possible according to the order we receive them and the level of need. After we determine the best resource match, we will contact you to talk through next steps.
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