Social Services Referral Form - Sam L. Martin Middle School
Family Resource Center
Social Services Referral Form
The Family Resource Center provides social services and case management (when necessary) to support and stabilize students and families who are at risk or in crisis.
Date of referral: ___________________________
Parent Name: _________________________________________ Phone: _____________________
Is parent aware of the referral? ( Yes ( No ( Unsure
Student Name: ________________________________________ Student ID# : _________________
Grade: _________ School: __________________________________________________
Please check all issues that apply to this FAMILY:
( Housing ( Employment/financial ( Basic needs (food, clothing)
( Legal ( Health insurance ( Health/Mental Health
( Parent/family /student relationship issues ( Other: ____________________________________
AND/OR
Please check all issues that apply to this STUDENT:
( Academics (Attendance ( Emotional /Behavioral Support ( Medical Issues
( Discipline ( Other: _____________________________________________________________________________
Is the student currently being served by other support services? (Check all that apply)
( CIS ( PSS ( Social Worker ( Other: ___________________________________________________
Has student issue/need been reviewed by the Child Study Team prior to FRC referral?
( Yes ( No ( Unsure If yes, to what outcome?__________________________________________
Please describe reason for referral:
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Person Making Referral: ( I prefer to remain anonymous
Name:_____________________________________________ Title: _________________________________________
Phone:____________________________________________ Email: ________________________________________
If referral is from a school other than where the FRC is located, please obtain parent signature below as consent for referral to the FRC for social services.
____________________________________________ _________________________________________ ____________________________
Parent Name Parent Signature Phone
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