School Referral Form
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YOUTH'S NAME
*
First
Last
PLEASE CHECK ANY OF THE FOLLOWING ISSUES THAT APPLY:
Peer Conflicts
Mental Health
BCOP (Beyond Control of Parent)
Attendance
Family
Running Away
Academic Performance
Suicidal
Gang Involvement
Suspensions
Expulsion(s)
Violence/Aggression
Behavioral Referrals
Substance Use
Suicide Risk Assessment Completed
Threat Assessment Completed
Other
PARENT/GUARDIAN NAME
First
Last
PHONE NUMBER FOR YOUTH OR PARENT/GUARDIAN
*
EMAIL
REFERRING PERSONS NAME
*
PHONE NUMBER
EMAIL
PARENTS/GAURDIANS CAN ALSO CALL US AT 208-544-4357 TO SCHEDULE AN APPOINTMENT
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