FRC Referral (Professional Staff)
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Make a Referral
1.
Today's Date
*
2.
Person Referring Family
*
3.
School/Organization
*
4.
Position
*
--Please Select--
Administration
Counselor
Evaluation Specialist
Intervention Specialist
LSSP
Parent/Guardian
Parent Liaison
Prevention Specialist
Stay in School
Social Worker
Teacher
Other
5.
If other, please explain
6.
Contact Number of Referring Party
*
7.
Email Address for Referring Party
*
8.
Student's Name
*
9.
Home Campus of Student
*
10.
Student ID #
11.
Student's Grade Level
*
12.
Does student receive any Special Education Services?
*
--Please Select--
Yes
No
13.
Does student receive 504 services?
--None--
Yes
No
14.
Student's Birth Date
*
15.
Does the student have medical insurance?
*
--Please Select--
Yes
No
16.
If Guardian, is there legal documentation?
--None--
Yes
No
N/A (Parent)
17.
Parent/Guardian Name
*
18.
Parent/Guardian Home Address
19.
Phone Number
*
20.
Cell/Work Number
21.
Parent/Guardian Language(s) Spoken
*
English
Spanish
Other, please specify
22.
Parent or guardian is currently active duty or has prior military service
--None--
Yes
No
23.
Has a risk assessment been completed within the last 6 weeks?
*
--Please Select--
Yes
No
Unsure
24.
Primary Needs Expressed by Family
*
Individual Counseling
Family Counseling
Group Counseling
Medicaid/CHIP Assistance
Parenting Class
Psychiatric Evaluation
Substance Abuse Counseling
Other, please specify
25.
Please describe any academic or behavioral need(s) that contributed to the reason for referral
26.
Campus Personnel who may be contacted to report on campus needs of student
27.
Additional Information:
28.
Date referral was discussed with the family and family informed referral source will be contacted by FRC Staff
*