SLIDE 5 7/25/2011 5
Who can refer?
- Police School Liaison Officers
- School Staff (principal, counselor, school
social worker, special ed teachers)
Referral for Service School Resource Counselor Referral Date: _________ New Referral
Date received: ________________
Referral Update/Change
SRC Worker: ____________________________________Contact Date: _________________ Student Name: (Last, First, MI) Birthdate: Sex: Male Female Student’s Address: City, State, Zip Code: Student’s Telephone Number: Mother’s Name: Mother’s Address: Same as child Mother’s Telephone Number: Father’s Name: Father’s Address: Same as child Father’s Address: Same as child Student’s School: Student’s Grade: Homeroom #: Race: White Black Asian Indian Hispanic: Yes No Other Referred By: Total Number of Suspensions: Number of Suspensions this Year:
Major problems/symptoms/family dynamics/concerns:
AODA issues Criminal conduct ADHD Family conflicts Anxiety Violent/Aggressive Anger Management Low IQ/DD issues Gang involvement Mental Health Truancy Issues Thought disorder/psychosis School failure/lack of motivation At-risk of School Expulsion/suspension Poor decision making/problem solving Lacks Social Medications, if yes what kind: ___________________________________________________________________________________ History of abuse Special Classes/IEP/Learning Disability: __________________________________________________________________________ Suicidal
Services Requested: (be specific)
0-3 months 3-9 months 9+ months Clients Length of Time
