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Staff Student Referral
Fill out the form below to communicate any concerns.
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Email
*
Your email
List the student's first and last name.
*
Your answer
Academic Concerns (Check all that apply)
falling grades
trouble understanding in a class
need help studying
struggling with being organized
other
Relationship Concerns (Check all that apply)
problems with my family
problems with a friend or friends
being bullied
struggling with social interactions
fighting with other classmates
problems with boyfriend/girlfriend
Emotional Wellness
anxious/worried
sad/depressed
overwhlemed
angry/frustrated
other
Behavior Concerns
hardtime paying attention in class
arguing
cannot sit still
fighting
experimenting with drugs/alcohol
trouble following rules/directions
other
Explain anything else I need to know.
Your answer
Thanks for taking the time to fill this out! I will get in contact with you soon! -Amanda
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