STAR and VIP Referral Form
This form is only for use by the referring school staff only. The information provided on this form will help us identify the best program/placement for the student.
Email address *
Referring school *
Referring counselor name *
Your answer
Referring counselor e-mail address *
Your answer
Student last name *
Your answer
Student first name *
Your answer
Grade level of referring student *
To what program are you referring? *
Explain the reason for your referral. *
Your answer
Is the student currently on suspension/expulsion? *
Required
If you answered yes to the previous question, please explain the reason for the suspension/expulsion.
Your answer
Does the student have a history of violent/anti-social bullying behavior? *
Required
If you answered yes to the previous question please explain.
Your answer
Has the student ever been truant? *
Required
Does the student qualify for any or all of the listed services? *
Required
Does the student have one of the following? *
Required
If the student has an IEP or 504 plan, please indicate the latest review date and identify all required accommodations.
Your answer
Has the student attended Orion Diploma Completion in the past? *
Required
If you answered yes to the above question, please indicate which location and program you attended.
Your answer
In your opinion, will the student be supported by their parents while attending the STAR or VIP program? *
Required
Please provide the name and phone number of the student's parent/guardian. *
Your answer
Please provide any additional information that might be helpful to ensuring your student's success at Orion DCP.
Your answer
A copy of your responses will be emailed to the address you provided.
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