Deering JMG HSC - Student Referral Form

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High School Completion and Dropout Prevention Services for Deering High School.

High School Completion Specialist: Kaylin Kerina
Email: kerink@portlandschools.org
Work Cell: 207-370-1104

Student Referral Form

Please be be as specific as possible, and feel free to email for more information or if you have questions!

Tier 3 Referral Criteria
-Student would be a good fit for the JMG Program
-Student meets 1 barrier listed
-Student needs multiple days a week support with school work
-Student needs weekly career guidance
-Student is eligible for free and reduced lunch
-Student will not graduate on time
-Student needs Edmentum monitoring multiple times per week

Tier 2 Level Referral Criteria
-Student would be a good fit for the JMG Program
-Student meets 1 barrier listed
-Student needs 1 weekly check-in for support
-Student needs PSE or Career guidance
-Student is eligible for free or reduced lunch
-Student needs Edmentum monitoring once a week

Tier 1 Referral Criteria
-Student meets 1 barrier listed
-Student needs biweekly check-ins

Edmentum Monitoring ONLY
-Student needs assistance with Edmentum monitoring
-Student needs bi-weekly check-ins

What Tier referral is being made: *

Tier 3

Tier 2

Tier 1

Edmentum ONLY

Other:

Required

Student Name *

Pronouns *

Intended Year of Graduation *

Is or has Student been enrolled in JMG? *

Yes

Unsure

School Counselor *

Social Worker *

Bob Carroll

Melissa McStay

Who will introduce Student to Ms. Kerina *

Does Student have IEP or 504? *

IEP

504

None

Other:

Required

Is Student able to attend regularly? *

Yes

Alternative Attendance

Not attending in school sessions

Online Only

Reduced Schedule

Other:

Required

At-risk for dropping out or not completing? *

Yes

Other:

Total credits earned *

Has this student been in any JMG programming before? What was the specialists' name? *

What specific classes are needed: *

Supports suggested by S.S.T. (check all that apply) *

Elective Online Credit Recovery

Attendance Support

Organizational / Executive Functioning

Post Secondary Transition Planning

Job Shadowing / Job Exploration

Referral to Goodwill Workforce Services

Vocational Case Management

Other:

Required

Barriers student faces to finish educational requirements:

Yes

ECONOMICALLY DISADVANTAGED

YOUTH IN CARE

DISABILITY

STUDENTS FACING INEQUITIES

POOR ACADEMIC PERFORMANCE

JMG ADVISORY COMMITTEE RECOMMENDATION

Additional things for Ms. K to know: *

Submit

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This form was created inside of Portland Public Schools.