BSMS YSC School Staff Referral Form
Do you have a concern about a student? Please complete the form to begin the process of connecting the student with resources within the BSMS Youth Service Center.

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
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Email *
Student's First and Last Name *
Student's Grade *
Is this referral for Academic Support? If yes, please check all that apply.  If no, check "Referral not for Academic Support. *
Required
Is this referral for Basic Needs? If yes, please check all that apply.  If no, check "Referral not for Basic Needs. *
Required
Is this referral for Health Needs? If yes, please check all that apply. If no, check "Referral not for Health Needs. *
Required
Is this referral for Mental Health/Counseling? If yes, please check all that apply. If no, please check "Referral not for Mental Health/Counseling? *
Required
What is your relationship to the student? *
Description of need (if known)
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