R.E.A.L. Referral Form
Student Information
Person Submitting Referral
First and Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Referring School
Please Select
Schoolfield Elementary
Woodberry Hills Elementary
Forest Hills Elementary
Other
Student's Name
First and Last Name
Gender
Please Select
Male
Female
Unknown
Other
Ethnicity:
Please Select
White/Anglo
Black/African American
Hispanic/Latino
American Indian/Native American
Asian/Pacific Islander
Bi-Racial
Other/Multi-racial
Grade
If Applicable
Parent/Guardian Name
First and Last Name
Parent/Guardian Phone #
Please enter a valid phone number.
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is student FAPT involved?
Please Select
Yes
No
Not Sure
Family Assessment and Planning Team (FAPT), helps troubled youths and their families.
Select services(s) of interest: (check all that apply)
In-School Mentoring/Support (School Based)
Tutoring and Academic Performance (Mentoring School Based)
Therapeutic Mentoring (Community Based)
Truancy Prevention/Intervention (Mentoring School Based)
Other
Additional Information (Please complete applicable items)
School Behavioral History/Indicators (Check all that apply)
Has NO history of Behavioral Issues
History of Expulsions
History of Suspensions (less than 10)
History of Suspensions (more than 10)
History of School Behavioral Issues
History of School Violence (fights, threats, damage to property)
History of Stealing
Decline in Academic Performance
History of Truancy/Attendance Issues
Aggressive/anti-social attitude
Suspected/known drug/alcohol use
Non-Compliant Attitude
Other
Select all applicable challenges below for the Individual referred (check all that apply)
Ability to avoid dangers/hazards
Anxiety
Community Linkage of Services
Anger
Daily living skills
Family Member(s) Incarcerated
Depression
Defiance/Authoritative Issues
Food Insecurities
Gang Affiliation/Involvement
Grief
Hygiene
Housing Insecurities
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Medication Education
Nutritional
Phobia/s
Parent/Guardian Guidance
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy/Attendance
Whole Health/Wellness
Other
Reason for Referral/Additional Information
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Submit
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