Social Service Referral
Grade 9 : Rydell High School
SSID : 101758
Race : W
DOB : 03/17/2006
Age : 14
HR Teacher : Lindsay Acosta
Referral / Case # 45
Submitted : 06/24/2020 08:30
PRESENTING ISSUE: DEATH IN FAMILY – IN CLASS BEHAVIOR – OUTSIDE CLASS BEHAVIOR
STUDENT
ALLEN, Andrew Parker
Grade 9, Rydell High
DESCRIPTION OF CONCERNS Andrew has been action up in class and also at basketball games. I spoke with his mother and she stated that his dad had passed away in the past few weeks and he is having a hard time with it.
REFERRED BY Anna Smith - Anna.Smith@bloombehavior.com
STUDENT INFORMATION
PARENT/GUARDIAN NAME Sarah Parker - Mother
PARENT/GUARDIAN PHONE
H : 256-233-0000
M : 256-527-0906
STUDENT ADDRESS 762, Sloan Lane, Athens AL, 35613
SSN XXX-XX-XXXX
MEDICAID NUMBER XXXXXXXXXXXX
PRE-REFERRAL ACTION TAKEN
ACTION
ALLEN, Andrew Parker
Grade 9, Rydell High
ACTION BY Anna Smith - Anna.Smith@bloombehavior.com
SCHOOL ASSIGNED SOCIAL WORKER Jack Brown - Jack.Brown@bloombehavior.com
Class/Course
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