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 #:

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

  conflict with teachers/staff

  assaultive/physically aggressive behaviors toward:

          peers       staff       family

  verbal aggression/threats/swearing toward:

          peers       staff       family

  truancy

  failure to complete school work

  negative peer interaction

  withdrawn

  possession of weapon at school (specify weapon)

  lack of motivation

  inability to remain on task

  poor socialization skills

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

  tobacco/smoking in school

  property damage

  self injurious

  other (explain):

 

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