Central Consolidated School District
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Cultural Assistance Team - Intake and Screening Form

1. Student ID (Must be 9 digits):*
2. School:*
3. Student expresses symptoms of (Select on all that apply):*
4. Referred by (Name):*
5. Referred by (E-mail):*
6. Reason for referral:

Central Consolidated School District
Terri Benn, Interim Superintendent
P.O. Box 1199, Highway 64, Old High School Road
Shiprock, New Mexico 87420
Main line: (505) 368-4984
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