Julian Request for Assistance SY24
If your child/student might benefit from some additional social/emotional support, please complete this form.

The Julian Tier 2 team will review the request at their biweekly team meeting to make a determination about whether or not Tier 2 supports would be appropriate. A member of the Tier 2 team will get back to you with a response following their biweekly meeting.

Tier 2 supports include:
- DePaul small groups, led by a licensed clinician
- Check In Check Out, led by a Julian staff member
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Email *
Student Last Name *
Student First Name *
Student Grade level *
Who is making the referral? *
What Tier 2 support is being requested for this student?
 *
Is the student receiving any special services or have educational plan? *
Please check all that apply.
Required
Current Language & Literature Grade *
Current Math Grade *
How many days of school has the student been absent so far? *
Provide an observable and measurable description of the behavior (s) you are noticing (what, when, where, with whom, duration, etc) *
Student Strengths *
Check all that apply.
Required
Current Intervention(s) used to address area of concern
Check all that apply in each Tier
Tier 1 Interventions (if known)
Check all that apply that have been used to address the area of concern.
Tier 2 Interventions (if known)
Check all that apply that have been used to address the area of concern.
What contact has been made about concerns to or from the student's family? *
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