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