BRIEF COMMUNITY INTERVENTION PROGRAM REFERRAL (SCHOOLS) Name of person(s) making referral: Date: Student’s Name: DOB: ☐ Male ☐ Female School: Current Grade: School/Resources: ☐ IEP* ☐ 504 ☐ YIC ☐ Other Languages Spoken in the Home: ☐ English ☐ Spanish ☐ Other: Interpreter Needed: ☐ Yes ☐ No Parent/Guardian: Signed parental release Yes ☐ Home #: Work #: Address: Email: CURRENT SCHOOL PROGRAMMING: ☐ Truancy Mediation ☐ Social Skills Instruction ☐ Tutoring ☐ Functional Behavior Assessment ☐ Behavior Intervention Plan School Case Manager and Phone Number: Other Community Partner/Agency Worker (DCFS, System of Care, JJS, Juvenile Court, LMHA): Describe school behavior interventions that have been implemented (what worked or didn’t?): REASON FOR REFERRAL: Describe student strengths, likes, dislikes, interests and any positive school involvement (sports/clubs): Reason for referral (why does student require intervention) and why they are considered at-risk (enter reason below): Attendance (days missed): GPA: Office Disciplinary referrals: Out of school suspension (days): On track for graduation: ☐ Yes ☐ No Other applicable information: PLAN/GOAL FOR STUDENT: Describe the goal for the student: Positive behaviors to increase (e.g., problem solving, communication, social skills): Risk behaviors to decrease (e.g., noncompliance, emotional outbursts, class disruptions): *Service delivery decisions must be made through the IEP process
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BRIEF COMMUNITY INTERVENTION PROGRAM REFERRAL (SCHOOLS)
Name of person(s) making referral:
Date: Student’s Name: DOB: ☐ Male ☐ Female
School: Current Grade: School/Resources:
☐ IEP*
☐ 504
☐ YIC
☐ Other
Languages Spoken in the Home:
☐ English ☐ Spanish
☐ Other:
Interpreter Needed: ☐ Yes ☐ No
Parent/Guardian:
Signed parental release
Yes ☐
Home #: Work #: Address:
Email:
CURRENT SCHOOL PROGRAMMING:
☐ Truancy Mediation
☐ Social Skills Instruction
☐ Tutoring ☐ Functional Behavior Assessment
☐ Behavior Intervention Plan
School Case Manager and Phone Number: Other Community Partner/Agency Worker (DCFS, System of Care, JJS, Juvenile Court, LMHA):
Describe school behavior interventions that have been implemented (what worked or didn’t?):
REASON FOR REFERRAL:
Describe student strengths, likes, dislikes, interests and any positive school involvement (sports/clubs):
Reason for referral (why does student require intervention) and why they are considered at-risk (enter reason below): Attendance (days missed):
GPA:
Office Disciplinary referrals:
Out of school suspension (days):
On track for graduation: ☐ Yes ☐ No
Other applicable information:
PLAN/GOAL FOR STUDENT:
Describe the goal for the student:Positive behaviors to increase (e.g., problem solving, communication, social skills):
Risk behaviors to decrease (e.g., noncompliance, emotional outbursts, class disruptions):
*Service delivery decisions must be made through the IEP process
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