SY 23.24-TLHS COORDINATION OF SERVICES TEAM (COST) REFERRAL
For students with issues of ATTENDANCE, BEHAVIOR, & ACADEMICS.

COST is a multidisciplinary team of school staff/providers who meet weekly to review individual and schoolwide student needs. COST members collaborate on linking referred students to resources & interventions to support academic and healthy overall development 

*Please note: School staff may not necessarily receive information about the student after submitting a COST referral, if the student or parent has declined further release of private health information. 
Email *
Name of referring staff: *
Today's date: *
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Student's first and last name you are referring:  *
Grade: *
Gender identity (if known):
Student's medical insurance provider (if known):  *
Primary language of student:  *
Primary language spoken at home (if known):
Reason for COST Referral: *
Is the student aware you made this referral? *
Required
Has the family been informed that you made this referral? *
Required
Interventions Attempted Thus Far:
Does the student have disciplinary issues that may involve: *
Required
Academic Needs (Check all that apply): *
Required
Emotional/Behavioral Needs (check all that apply): *
Required
Social Needs (Check all that apply): *
Required
Health/Basic Needs (Check all that apply): *
Required
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