Student Resilience & Empowerment Center Student Inquiry Form

Name *

First

Last

Age

Selected Value: 10

Date of Birth (MM/DD/YYYY) *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Legal Guardian Name *

First

Last

Phone *

Email *

School Student is Currently Attending

School District

Grade Level

Selected Value: 6

Principal Name *

First

Last

Referring Staff Name (building key contact) *

First

Last

Referring Staff Email (building key contact) *

Referring Staff Phone (building key contact) *

Has an outpatient behavioral health service referral been made? *

If YES, what agency or agencies?

What are the student’s strengths related to school, home and the community?

What opportunities for growth does the student have related to school, home and the community?

What supports are currently in place for this student?

What goals are desired to be accomplished by attending the Student R.E.C?

Please make sure to complete this brief survey before submitting your inquiry

Please attach the REC consent form any relevant documents (504 plans, etc) *

Click or drag files to this area to upload. You can upload up to 4 files.