DROP-IN REFERRAL FORM

The Drop-In Center School Based Youth Service Program Hackensack High School ●135 Beech Street, Room 161 ● Hackensack, NJ 07601 (201) 646-0722 ● FAX (201) 646-1558
DROP-IN REFERRAL FORM

Thank you for taking the time to complete this referral form. Please be advised that you may receive an e-mail with additional questions concerning this referral. Confidentiality laws prohibit us from disclosing student progress in the program without the student’s and parents’ written permission.
Date of Referral

MonthDayYear
Date
Student's Name

First NameLast Name
Grade

GradeStudent Id#:
Student's Primary Language
Do you think this student may be at risk? If so, please contact a Building Administrator and follow risk screening (RA) procedure and fill out the risk screening form.
Staff Name:

First NameLast Name
Do you have extension you can be reached at? If you cannot be reached at an extension we will contact you via e-mail.

Area CodePhone Number/Ext.
Staff Email:
example@example.com
If this student has an IEP, did you notified the Case Manager about your concerns?
Is the student aware of the referral to Drop-In?
**Please select all behaviors or reasons that you would apply to the nature of the referral**

Other
Academic Issues: If the students is missing assignments or not attending class, please reach out to the Grade Level Administrator.
Brief Description of above:
Should be Empty: