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