Gateway Referral

1) Which school does this student attend? *
2) Who is requesting the referral?: *
Is student transferring from another school and is currently receiving Gateway services? *
6) Gender *
9) What is the student's Ethnicity? (check all that apply) *
10) Lives with: *
15) Parent phone language (check all that apply): *
17) Did you speak with parent?
18) Is this student currently receiving special education services? *
21) Reason for referral:
Difficulties with mood/affect
Behavior problems
Difficulties with peers
Academic difficulties
Family-related difficulties
Alcohol tobacco & other drugs (ATOD)
Trauma (i.e.; car accident, witness or victim of violence, life threatened by another or natural disaster, etc.)
22) Previous Interventions (check all that apply):
Services previously provided by a GTS Intern (GTS client file available)?
23) What type of insurance, if any, does the student have?
0/250 words
You must check YES for your referral to be submitted. *

Contact your site Gateway Counselor if you have any additional information or questions regarding this referral. THANK YOU!

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