2021-22 Lincoln Alternative Academy Counselor Referral
School Counselors - Please complete this student referral form for a student to be considered for enrollment at Lincoln Academy. All responses will be kept confidential and be used as part of the intake / screening process for student enrollment at Lincoln Alternative Academy. Thank you!
Email *
Student Last Name *
Student First Name *
Today's Date *
Grade *
Referring School *
Referring Counselor *
Have you visited with your site administration about submitting this referral and are they supportive of the recommendation? If not, please visit with them first before submitting. Thanks! *
If you answered Co-op school above, please list the school and referring counselor
If the student is new to Stillwater and is requesting a referral to be considered at Lincoln Academy, where did the student last attend school? (city, state, and name of the school). *
Date of Birth *
Age? *
Is the student behind a grade in their class cohort? *
Please list the student's current GPA. *
Credit Deficiency according to cohort class. *
Behavior Interventions
If you listed "Other" above, please share information.
Attendance - Previous Semester *
Please list the main reasons for the student's absences? *
Please share the student's main reason for wanting to attend Lincoln Academy. *
Please check the following criteria that applies to the student which should be considered for enrollment at Lincoln Alternative Academy. *
If you marked "Other" on the previous question, please explain.
Please check the following state or federal programs that support this student? *
If you answered yes to being on an IEP, what areas of support did the student receive (Math, Reading, Behavior, etc.)?
If you answered yes to any other state or federal programs, please share information to describe and support provided.
How long has the student been at your school site? *
Has a behavioral intervention plan been implemented? *
Have counseling services been implemented? *
If you answered yes to counseling services, please share information. (Counselor / Agency & Frequency)
Please share any other relevant information you feel we should know about this student as they're being considered for enrollment at Lincoln Academy? Thank you for your time! *
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