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TIP Referral Form
Please use this form to refer cases to TIP for assistance. We will contact you to confirm that the referral has been accepted. If you have any questions, please contact Adrian Wright at
awright@truancyproject.org
.
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* Indicates required question
Referral Date
*
MM
/
DD
/
YYYY
Child's First Name
*
Your answer
Child's Last Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Parent/Guardian First Name
*
Your answer
Parent/Guardian Last Name
*
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Parent/Guardian Phone Number
*
Your answer
Child's Phone Number (if applicable)
Your answer
Current School (for elementary schools, please note that we can only assist children attending one of our seventeen Early Intervention Schools)
*
Your answer
Current Grade
*
Your answer
School Social Worker who made referral to CHINS:
Your answer
Please indicate if any of the following services are needed or suspected to be needed:
Special education (IEPs, 504 plans, eligibility help)
Disciplinary Tribunal
Housing Assistance (eviction or housing conditions help)
Homelessness/McKinney-Vento issues
Transportation assistance
Mental Health (parent or child)
Substance abuse
Other legal issues (unpaid wages, government benefits, Medicaid/Medicare)
Other:
Please describe efforts made to assist the child and family thus far:
*
Your answer
Please indicate how TIP may be able to help:
*
Your answer
Referral made by:
*
Your answer
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