Editing previous response:

Please fix the highlighted areas below before submitting.

Statewide School Support Referral Form




Statewide School Support Referral Form


Authorization to release information (one form per student) must be signed by the parent / guardian and received by Statewide School Support Services prior to scheduling a visit. Please scan and email the completed form to [email protected] with "Authorization to Release" in the subject line.

Authorization Form

Formulario de Autorización

I. Requestor Information

II. Supervisor Information

III. Type of service requested (select all that apply)*
Answer Required

IV. Interpreter Contact Information

Confirmation Email