Referral date: *

Student name: *

Student’s RCPS ID#:

Gender: *

Ethnicity: *

School: *

Grade: *

Birth date: *

Age: *

Student address: *

Zip: *

Parent/Guardian name(s): *

Home phone:

Cell phone: *

Work phone:

Custodial Rights: *

Does the student have a current IEP? *

If yes, Case Manager name:

Consultant name:

Does the student have a Section 504 Plan? *

Does the student and/or parent/guardian require an interpreter? *

If yes, what language:

Who is making this referral?: (Name) *

Referrer is a: *

Referral source’s phone #: *

Referral source’s email: *

To which School Counselor is this student assigned? *

School Counselor Phone #: *

School Counselor Email: *

Has this student been staffed with your school’s RTI/SST/AST? *

Date case was staffed or will be staffed (if applicable): *

In addition to this referral, please check any previous actions that have taken place in regard to this student? *

Does this student exhibit any of the following warning signs for at-risk behaviors? Early Warning Signs (low-to-medium-risk factors/behaviors) *

Imminent Warning Signs (high-risk factors/behaviors) *

What prompted this referral? What are your concerns about risk? Any additional comments you would like to include? *

Has the family been notified that a referral for behavioral interventions has been made? *

Name of family member contacted: *

Has family member signed Consent for Behavioral Health Screening and/or services? *

OTHER PROFESSIONALS INVOLVED WITH STUDENT *

For each yes, enter corresponding information below. (Names, Agencies, Phone Numbers)

SERVICES RECOMMENDED/REFERED: *

If School-Based MH Services recommended, who will contact AFE with referral information? (Name, Title, Phone Number)

I verify and acknowledge that I have reviewed all of the information contained in this document. (Full Name) *