• EXTENDED FAMILY PROGRAMS

  • Day Treatment Referral Form - Elementary, Middle and Secondary
    Po Box 620, Bedford PA 15522 * Ph: (814) 623-1770* Fax: (814) 623-1715

  • M/F
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • This referral is for the traditional school day (8:00 am to 3:00 pm)
    *** Students must attend at least 45 school days and consistently meet daily goals before staff will recommend the return to the home school district A review of the student's goals will be completed every 30 school days.

  • Estimated length of stay
  • Other agencies involved with the child include:
  • *** Copies of the following information (if applicable) MUST be submitted before consideration for enrollment:
  • Has this child ever been in placement before?
  • *** Does this child have a current IEP?
  • *** If the student is 14 or older, does he/she have a transition plan incorporated with the IEP?

  • If yes, indicate the responsible party for this service

  • *** Reasons for referral/presenting problem: (Please explain reason for referral and supply any supporting documentation)

    Extended Family Programs is a Day Treatment serving youth (students K-12)

  • As the referral source, I have informed the family about the reasons for referral, estimated length of stay, and the expectations for return to the home school.
  • As the parent/guardian, I understand the reasons for the referral, the expectations of the referral source, and the length of stay for my child.
  • Date
     - -
  • As the referring agency, I understand that I will seek and/or arrange funding for the above child's enrollment with Extended Family Programs.
  • Date
     - -
  • It should be noted that each child will have an Individual Service Plan completed by EFP Staff within the first 30 days. Updates to that plan are completed on a regular basis. Parents, as well as other agencies involved with the child, will be invited to the ISP meeting. The IU-08 teacher will address any educational needs while the student is enrolled at EFP.

  • All information marked with *** MUST be completed before the referral will be accepted for review.

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  • Should be Empty: