Viking TNT Referral
This program targets children who are in foster care and those who are not with social-emotional or behavior issues who could benefit from receiving mental health services.
* Required
Your name (Referring person)
*
Your answer
Student's name
*
Your answer
School
*
Choose
Lincoln
Garfield
Guthridge
Middle School
High School
Is the student in foster care?
*
Yes
No
Does the student have an IEP?
*
Yes
No
Is the student currently receiving mental health services?
*
Yes
No
Unsure
If yes, what services are they receiving? Click all that apply.
Navigators
Therapy
Case management
Have you completed a SAEBRS assessment?
*
Yes
No
Describe your concerns (academics, behavior, attendance).
*
Your answer
Has the student been brought to SIT?
*
Yes
No
Other:
What have you tried (interventions) to address these concerns?
*
Scheduled Breaks
Fidget/sensory items
Alternative seating
Incentives
Data behavior chart
Student visual/written out schedule
On going conversations with parent(s)
Has seen school counselor
Office referral
Behavior plan
Small groups (ie “families”, lunch bunch, Viking TNT, etc.)
Outreach to Charla
Other:
Required
Have you spoken with your principal and are they in agreement that this student is a good candidate for the pilot?
*
Yes
No
Other:
Describe the parent/caregiver's knowledge of your concerns? Who did you speak to?
*
Your answer
Have you mentioned to the parent that you are referring the student to the pilot and are they interested?
*
Your answer
When is a good time during the day that is the best to pull the student out of class?
*
Time
:
AM
PM
Submit
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