RCPS Behavioral Intervention Referral Form
To Be Completed By Referral Source or School Counselor
Referral date: *
Student name: *
Student’s RCPS ID#:
Gender: *
Ethnicity: *
School: *
Grade: *
Birth date: *
MM
/
DD
/
YYYY
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): *
MM
/
DD
/
YYYY
In addition to this referral, please check any previous actions that have taken place in regard to this student? *
Required
Does this student exhibit any of the following warning signs for at-risk behaviors? Early Warning Signs (low-to-medium-risk factors/behaviors) *
Required
Imminent Warning Signs (high-risk factors/behaviors) *
Required
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 *
Yes
No
Child Welfare Services
Mental Health Provider
Physical Health Provider
Juvenile Court
DJJ
For each yes, enter corresponding information below. (Names, Agencies, Phone Numbers)
SERVICES RECOMMENDED/REFERED: *
Required
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) *
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