STUDENT INFORMATION

Date: Click or tap to enter a date.	Referral Submitted by: , Choose an item.
Referring District: Choose an item.	School of Attendance:
Student’s Name:	Student ID:	Student’s DOB: Click or tap to enter a date.
Student’s Case Carrier:	Case Carrier Email:
Student Address: , CA
Student resides with: ☐Parent ☐ Other:
Educational Rights Holder: ☐Parent ☐Student ☐Other:

IEP INFORMATION

Current IEP Dated: Click or tap to enter a date.
Primary Disability: Choose an item.	Secondary Disability: Choose an item.
Goals in:	☐Academics	☐ Communication	☐ Behavior	☐Social Emotional
Current Services: (if checked, indicate current service minutes and frequency)	☐ Specialized Academic Instruction minutes/Choose an item.	☐ Language and Speech Services minutes/Choose an item.
☐ Occupational Therapy minutes/Choose an item.	☐ School Based ERMHS Counseling minutes/Choose an item.
☐ Behavior Intervention Services minutes/Choose an item.	☐ Social Work Services minutes/Choose an item.
☐ Intensive Individual Services (1:1) minutes/Choose an item.	☐ DIS Counseling minutes/Choose an item.
Current Placement:	☐ GenEd Classroom ☐ Special Day Class ☐ Nonpublic (NPS)
Other Agency Involvement:	☐ Regional Center	☐ Department of Rehabilitation	☐ Other:

PREVIOUS INTERVENTIONS

Intervention/Support	Date Initiated	Date Completed	Outcome
Click or tap to enter a date.	Click or tap to enter a date. ☐Current
Click or tap to enter a date.	Click or tap to enter a date. ☐Current
Click or tap to enter a date.	Click or tap to enter a date. ☐Current
Click or tap to enter a date.	Click or tap to enter a date. ☐Current
Click or tap to enter a date.	Click or tap to enter a date. ☐Current
Click or tap to enter a date.	Click or tap to enter a date. ☐Current
Click or tap to enter a date.	Click or tap to enter a date. ☐Current

CURRENT OBSERVATIONS RELEVANT TO REFERRAL

What behaviors are of primary concern?

Describe the student’s relationships with peers.

Concerns pertaining to mental health.

DOCUMENTS ATTACHED

☐ Most recent Annual IEP	☐ Most recent assessments
☐ Subsequent Amendments	☐ Psychoeducational (Required)
☐ Most recent Triennial IEP	☐ District ERMHS (Required)
☐ Behavior Intervention Plan (if applicable)	☐ Speech and Language (If applicable)
☐ Discipline records	☐ Occupational Therapy (If applicable)
☐ Grades	☐ Functional Behavior Assessment (If applicable)
☐ Transcript (HS only)
☐ Attendance (current year and SART/SARB history)
☐ State test scores (most recent)
☐ Enrollment information (dates of enrollment at each school/district)