ST. STEPHEN'S

LUTHERAN ACADEMY

 

Day Student Referral Form

Referral Source:

Parent/Guardian's School District:

Date Completed:

Contact Person:

Title:

Address:

City, State, ZIP:

 

Phone #:

 

Student Information:

Name:

Gender:

Male     Female

SS #:

PA Secure ID #:

Age:

DOB:

Grade:

Address:

City, State, ZIP:

 

Phone #:

 

 

Contact Information for Legal Guardian:

Relationship to Student:

Name:

Address:

Phone #:

 

*These items must be forwarded prior to enrollment:

Special Education Students:

All Students:
  IEP*   Report cards*

  ER*  Does ER reflect current placement recommendations?    Yes    No

  Immunization Records (do not send originals)*

  NOREP*

  State School Health Record (do not send originals)*

  Educational/Psychological report

*Please be aware that St. Stephen's will require a credit count for high school students prior to the initial IEP meeting, so that we can do appropriate planning for the student.

 

Reason for Referral (check all that apply):

defiance of school/classroom rules

assaultive/physically aggressive behaviors toward:

          peers       staff       family

*failure to complete school work

truancy

*withdrawn

negative peer interaction

*lack of motivation

possession of weapon at school (specify weapon)

*inability to remain on task

verbal aggression/threats/swearing toward:

          peers       staff       family

*poor socialization skills

 drug and/or alcohol involvement (note which substance if known)

property damage

 tobacco/smoking in school

 *self injurious
conflict with teachers/staff  other (explain):

(*)Behaviors are more typically associated with students with Austism Spectrum Disorders but not exclusive to this population of students.

Interventions:

Is the student currently in school?    Yes       No

If no, state reason: 

If student is currently expelled, please state reason and length of duration:

Has the student been retained?     Yes      No

If so, what grade(s)? 

Suspension(s):     Frequently      Rarely

Date/Reason: 

Law enforcement:     Yes      No

Date/Reason: 

Probation:     Yes      No

If yes, name of probation officer: 

 

Ability/Achievement:

Reading Level (grade equivalent): 

Math Level (grade equivalent): 

Full Scale IQ: 

Date of most recent evaluation: 

 

Psychiatric:

Date:                                                                         Examiner: 

Axis I:   

Axis II:  

 

Educational Services:

    Speech Services

  Physical Therapy

  English Second Language

    Hearing Services

  Vision Services

  Other 

    Occupational Therapy

  OVR

 

Community Services (Agencies):

1. 
2. 
3. 

 

Psychiatric hospitalizations, alternative school placements, legal and/or residential placements:

 

When

Where

Duration

Discharge Date

Psychiatric

Hospitalization(s)

Alternative School

Placements

Legal

Placements

Residential

Placement(s)

 

rev. 09/02; 11/02; 12/02; 05/05; 02/06; 4/09