FRC Referral (Professional Staff)

1.	Today's Date*

2.	Person Referring Family*

3.	School/Organization*

4.	Position*
	--Please Select--AdministrationCounselorEvaluation SpecialistIntervention SpecialistLSSPParent/GuardianParent LiaisonPrevention SpecialistStay in SchoolSocial WorkerTeacherOther

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--YesNoN/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--YesNoUnsure

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*