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* 1. Please select reason for referral. May select more than one (MTSS, Behavior & DIAT If checking Emergency Suspension answer questions in Blue 1-10 and 25.)

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* 3. Date of referral:

Date / Time

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* 4. Student Name:

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* 5. Student ID:

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* 6. Grade:

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* 7. DOB:

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* 8. Special Education?

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* 9. If student is in special education, who is the case manager?

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* 10. 504:

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* 11. CIT:

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* 12. Wrap-around supports? (i.e. Juvenile justice, WIN,social services, CBS, Quest)

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* 13. If there are wrap-around supports in place, please specify below what is in place.

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* 14. Have any of the following people been involved?
Check all that apply:

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* 15. Check all that apply:

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* 16. Someone in your building who has a positive relationship with the student:

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* 17. Someone in your building who has a positive relationship with the family:

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* 18. Primary administrator for the student:

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* 19. Primary point of contact at the site:

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* 20. Assigned Counselor:

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* 21. Additional factors to be considered:

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* 22. Has the student been placed on an Emergency suspension before?

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* 23. Has the student been through SARB?

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* 24. Has the school team started or completed the PTR (Prevent, Teach, Reinforce) process?

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* 25. Summary of the concerns:

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* 26. Goal for requesting support:

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* 27. Current MTSS Tier

T