CCPS "COMPLETE CONTROL" PROGRAM REFERRAL FORM (SECONDARY)

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A VIRTUAL ANGER MANAGEMENT AND SELF-REGULATION PROGRAM (High and Middle School Referral Form)

Disposition Code: 6117

Complete Control is a Weekly One-Hour 2-Day Virtual Program. Program Sessions are held on Tuesdays and Wednesdays of the SAME WEEK, from 5:00 pm to 6:00 pm. You must select and attend two back to back sessions in the same week (One session on Tuesday and the second session on Wednesday)

In the event of an emergency resulting in the student being unable to login and participate in the program as scheduled, the principal of the student’s school should be notified immediately.

ONLY ADMINISTRATORS MAY INITIATE REFERRALS TO ALTERNATIVES TO SUSPENSION PROGRAMS (ATS). CIRCLE OF SUPPORT MEMBERS MAY INTITIATE REFERRRALS/CHECK THE OPTION TO USE THE PROGRAM AS A PREVENTION MEASURE (PREVENTION-ALTERNATIVES TO SUSPENSION PROGRAMS: P-ATS)

Email *

Today's Date *

YYYY

Please select your FIRST SESSION on TUESDAY: *

YYYY

Please select your SECOND SESSION on WEDNESDAY of the SAME WEEK *

YYYY

LINK TO TUESDAY AND WEDNESDAY SESSIONS YOU SELECTED: https://clayton-k12-ga-us.zoom.us/j/95032407487

SCHOOL *

STUDENT'S FIRST AND LAST NAME *

STUDENT GRADE *

STUDENT DATE OF BIRTH *

YYYY

STUDENT ADDRESS *

PARENTS/GUARDIANS' FIRST AND LAST NAME *

PARENT/GUARDIAN EMAIL ADDRESS (REQUIRED) *

PARENT/GUARDIAN PHONE #:

STUDENT CODE OF CONDUCT ITEM. Write "NA" if referral is for Prevention. *

Describe Behavior of Concern *

STUDENT AGREEMENT: I have accepted the option given to me by the Clayton County Board of Education to attend the “COMPLETE CONTROL” program indicated above. In accepting this opportunity, I agree to abide by the guidelines and other conditions set forth in this program. I understand that up to six (6) days of suspension may be taken from my total suspension period for the above offense. I understand that if I do not login and complete the two sessions, I will be terminated from the program and the remaining days of my suspension will be enforced. I agree to attend and complete the session. I also agree to log in ten minutes before 5:00 pm each day and remain for the entire one-hour session. Link to Expectations for Participants: https://docs.google.com/document/d/16dxQIXycjVLNtOH-pkqSewkP32Zr0P1Jto9ud8D9XMc/edit?usp=sharing *

Student agrees and accepts option (Alternative to Suspension Program).

This Referral is a Prevention Measure.

PARENT AGREEMENT - As parent or guardian of the above named student, I agree to participate/ensure that my son/daughter logs in and completes the assigned “COMPLETE CONTROL” program sessions in order to give my son/daughter the opportunity to continue his/ her educational program in the school. Link to Expectations for Participants: https://docs.google.com/document/d/16dxQIXycjVLNtOH-pkqSewkP32Zr0P1Jto9ud8D9XMc/edit?usp=sharing *

Parent gives consent and agree to participate (Alternative to Suspension Program).

Parent gives consent for Referral as a Prevention Measure.

FIRST AND LAST NAME OF ADMINISTRATOR/CIRCLE OF SUPPORT INITIATING REFERRAL *

Next Step: After you Submit the Referral Form, you will automatically receive a copy of the referral you submitted in your Email. You must FORWARD a copy of this electronic Referral to the Program Contact/Facilitator and Parent to confirm Registration for the Program sessions. *

Next Step

A copy of your responses will be emailed to the address you provided.

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