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Student Engagement Plan
Student Profile
Name
First Name
Last Name
District
Please Select
Evergreen
White Salmon
Skamania
Ridgefield
Mt.Pleasant
Washougal
School
Grade
Referral Date
-
Month
-
Day
Year
Referral Source
Counselor/Program Lead Information
Name
First Name
Last Name
Position
Phone Number
Email
example@example.com
Would the referral source like to attend the Introduction Meeting with the student and parent? If so, you will be included on the zoom invite.
Yes
No
Health Insurance
Is the student insured?
Please Select
Yes
No
Interested in applying for Apple Care Health Insurance ages 0-18
Please Select
Yes
No
Insurance Company Name
Policy Holder
Group Number
Policy Number
Insurance Phone
Please enter a valid phone number.
Student Demographics and Contact Info
Date of birth
-
Month
-
Day
Year
Gender
Race
American Indian/Alaskan Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Other Pacific Islander
White
Two or More Races
Language Spoken by Student
Student Phone Number
Email (If any)
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian 1 Information
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Can we contact this parent regarding the student?
Yes
No
Parent/Guardian 2 Information
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Can we contact this parent regarding the student?
Yes
No
Parent/Guardian Additional Information
Language(s) Spoken
Has parent contact been made?
*
Please Select
Yes
No
Confidential (no parent contact)
Date of contact
-
Month
-
Day
Year
Date
Additional Student Information
Other program(s) student is enrolled in.
Community resources requested:
Any other information you think would be helpful:
Target Behaviors
Select the major areas of concern for which you are referring the student.
*
Inattentive, unfocused, off task, and distracted
Unprepared, no materials or books
Excessive movement, out of seat,fidgeting, not keeping hands to self
Poor organization, messy, and missing work
Impulsive, blurts out, disruptive, etc. Rushing through work, tasks, and directions
Disengagement, detachment, mood swings, lack of emotional regulation, isolation
Other
Intervention Plan
Objectives
*
Improve attention and focus on assignments, tasks, and instruction, reduce distractibility
Maintain organized and neat workspace, book bag, locker, folders, etc. Come to class with necessary materials, books, and supplies
Engage in extra movement in a non-disruptive and non-distracting manner
Reduce disruptions to class by raising hand, waiting to be called upon; thinking and pausing before doing, etc.
Take time and care with assignments, instructions, notes, etc.
Foster positive relationship skills, positive coping skills (journaling, art, exercise. etc.), Identifying emotions
Other
Health Advocate Coaching
Reminders to organize materials, backpack, and/or locker
Inquire/assist with homework as needed
Reminder of classroom norms and/or established plan
Reminder to check their planner, checklist, chart, or other tracking and monitoring forms, and getting signature as appropriate and relevant to the established plan
Other
Therapeutic Services
*
Health Advocate Only
National Certified Health & Wellness Coach
Therapist: LCSW (Known trauma or medical diagnosis needed)
Counselor/Program Lead Signature
Parent/Guardian Signature
Phone Number
Please enter a valid phone number.
Submit
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