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 *
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9) What is the student's Ethnicity? (check all that apply) *
 
10) Lives with: *
 
14) Parent phone language (check all that apply): *
 
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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): 
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24) 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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