Information on Person Making Referral:
Name of Person Making Referral:
First Name
Last Name
Role:
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Date of Referral
-
Month
-
Day
Year
Date
Referring School
Please Select
Dothan Brook School
Ottauquechee School
White River School
Hartford Memorial Middle School
Out of District Placement
Homestudy
Is the parent or guardian aware of this referral? (If not, please stop and obtain parental consent)
Have the following steps been completed by the student's school team?
Review of Universal Design Practices in classroom and school settings
Review of 504 or IEP accommodations
Educational Support Team (EST)
If any of the above have not been completed, please explain why:
Information on Student Being Referred:
Student Name
First Name
Last Name
Current Grade
Please Select
5th Grade
6th Grade
7th Grade
8th Grade
Age
Does the student have a history of placement outside of general education? If so, please provide details of what programs and at what grade level.
Please describe concerns resulting in this referral:
Guiding questions to consider regarding concerns: What are your academic concerns? What are you social, emotional and behavioral concerns?
Please describe the concerning behavior(s): Where, when, and with whom are they most likely to occur?
How many rule 4500 (use of restraint or seclusion) events has this student experienced prior to this referral? Please provide any additional information you feel is relevant:
What does the student enjoy and what are their strengths?
Please describe times/examples of when the student thrives, including relevant information around why these times/examples have been successful:
Please describe this student's academic needs and strengths:
Family Information
Name (s) of student's Parent or Guardian:
Parent or Guardian Phone Number:
Parent or Guardian Email:
Who lives with the student in their home?
Are there any known challenges that exist outside of school, if so, please describe:
Mental Health Information
Are there any known mental health diagnoses?
Is the student currently receiving mental health treatment? If so, with who:
Please provide contact information for any treatment providers:
Please upload relevant behavioral data, such as: FBA, BIP, SWIS, IC reports, etc
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Please upload a copy of the student's IEP, 504 Plan, or EST Plan, if applicable:
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Why do you believe this student is a good fit for the Phoenix Project Classroom?
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