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DHHS In-Take Referral

CODE: JLF- E1

Maine School Administrative District No. 31

DHHS IN-TAKE REFERRAL


Name of referent:_________________________________________________       Date of referral:_______________________        
                              
Child’s Name:______________________________________     Grade: __________     School:___________________________        

Name of parent or legal guardian:____________________________________________________________________________                                    

Address of primary guardian:  _______________________________________________________________________________                                  

Phone:________________________________________________            

Other Address if divorced: ___________________________________________________________________________________
                          
Phone: ________________________________________________           

Other children in the home with DOB: __________________________________________________________________________                              
                                                                                                  
Description of the situation/comments:




Name of person you spoke to: ___________________________________________         Time of report: _________________       

First Reading:        10/18/2006
Second Reading:    11/15/2006