School-Based Referral & Academic Information Form

LEO Clinic – School-Based Referral & Academic Information Form

Please complete all sections of this form. All required fields must be filled out accurately.
Student Information
Student Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Student Address

Street Address

CityState / ProvincePostal / Zip Code
Insurance Information
Current Insurance
Insurance Plan Number
Parent/Guardian Information
Parent/Guardian Full Name

First NameLast Name
Relationship to Student
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Parent/Guardian Address (if different from student)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Referral Type
Referral Source

If referred directly by school staff
Name of Person Making the Referral

First NameLast Name
School Student Attends
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral Email Address
example@example.com
Position
Reason for Referral
Referred for
Do you want an evaluation for medication management?
Referred for
Brief Description:
Academic History
School Name
Current Grade
Grades Skipped:
Grades Held Back:
Academic Strengths

Other
Academic Weaknesses

Other
Likes About School

Other
Dislikes About School

Other
Academic Performance:
Highest Grade Completed
Special Education / 504 Status
Individualized Education Plan (IEP) in Place/PPT?
If yes, specify the Special Education Needs ( check all that apply):
504 Plan in Place
Observed Coping Strategies (Check all that apply):

Other
Parent / Guardian Consent
Signature of Parent/Guardian
Date Signed

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

First NameLast Name
Should be Empty:

LEO Clinic – School-Based Referral & Academic Information Form

Student Information

Insurance Information

Parent/Guardian Information

Referral Source

Reason for Referral

Academic History

Special Education / 504 Status

Parent / Guardian Consent

Verbal Parent / Guardian Consent