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: *
14) Parent phone language (check all that apply): *
16) Did you speak with parent?
17) What type of insurance, if any, does the student have?
18) Is this student currently receiving special education services? *
19) Previous Interventions (check all that apply):
20. Reason for referral (check all that apply):
0/500 words
24) You must check YES for your referral to be submitted. *

**If student is in crisis, you must notify an administrator or Gateway Counselor before you submit a referral. Contact your site Gateway Counselor if you have any additional information or questions regarding this referral. THANK YOU!

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