LEO Clinic – School-Based Referral & Academic Information Form

LEO Clinic – School-Based Referral & Academic Information Form
Student Information
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Insurance
Insurance Plan Number
Parent/Guardian Name

First NameLast Name
Parent Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent Email
example@example.com
Referral Type
Referral Source

If referred dirctly by school staff
Name of Person Making Referral

First NameLast Name
School Student Attends
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Position
Reason for Referral
Referred for
Do you want an evaluation for medication management
AnxietyDepressionADHD/Attention DifficultiesTrauma/GriefBehavioral ConcernsSocial SkillsFamily ConflictSelf-InjuryPeer ConflictAdjustment/TransitionOther
Brief Description:
Academic History
School Name
Current Grade
Grades Skipped:
Grades Held Back:
Strong reading comprehension skillsExcellent memory and recallParticipates actively in class discussionsCreative thinker / strong imaginationGood problem-solving or reasoning skillsEnjoys hands-on learning or projectsDemonstrates leadership or teamworkMotivated and eager to learn in subjects of interestFollows directions well / organizedStrong writing or verbal communication skillsOther
Difficulty focusing or sustaining attentionPoor organizational skills / forgets assignmentsStruggles with reading or comprehensionDifficulty completing homework or turning in workTrouble with math concepts or problem-solvingEasily distracted or off taskDifficulty with transitions between subjectsAvoids challenging tasks / low frustration toleranceStruggles with test-taking or time managementInconsistent effort or motivationOther
Enjoys seeing friends or teachersLikes lunch, recess, or gymLikes specific subjects (e.g., math, science, art)Enjoys after-school programs or sportsLikes helping others / being part of a groupEnjoys learning new things / hands-on activitiesLikes structure and routineFeels supported by certain staff or peersOther
Feels bored or unchallengedDislikes certain subjects or teachersFeels anxious, bullied, or left outOverwhelmed by homework or expectationsDifficulty concentrating or staying seatedDislikes noisy or crowded environmentsFeels unsupported or misunderstoodFinds it hard to make or keep friendsReports not feeling safe or comfortableDislikes attending school / avoids classesOther
Academic Performance:
Highest Grade Completed:
Special Education / 504 Status
Individualized Education Plan (IEP) in Place/PPT?
AutisticCommunication ImpairmentDevelopmental DelayEmotional ImpairmentGifted/TalentedIntellectual ImpairmentNeurological ImpairmentPhysical ImpairmentSensory ImpairmentSpecific Learning DisabilityTraumatic Brain Injury
504 Plan in Place
Seeks supportWithdraws/IsolatesCryingDefianceAgressionAvoidanceSelf-Harm TalkOther
Parent/Guardian Consent

I consent for my child to be referred for behavioral health evaluation and/or treatment through LEO Clinic’s DCF-licensed Outpatient Psychiatric Clinic for Children. I understand the clinic may contact me to discuss scheduling, consent forms, and treatment options.
Signature

Clear
Date

MonthDayYear
Date
Verbal Parent/Guardian Consent
Verbal Consent
Parent/ Guradian Name

First NameLast Name
Parent/Guardian First Name Last Name Date verbal consent obtained Date by staff First Name Last Name .
Should be Empty:

LEO Clinic – School-Based Referral & Academic Information Form

Student Information

Referral Source

Reason for Referral

Academic History

Special Education / 504 Status

Parent/Guardian Consent

Verbal Parent/Guardian Consent