Crescent Academy Referral Application
Student’s Name
Date of Birth ____________
Home School
Student ID #
Grade Age
Address
__________________
Parent/Guardian’s Contact Information:
Parent/Guardian’s Name
Home Phone
Cell
Work Phone
E-mail
Student Support Services: (Please include initial placement dates for all that apply.)
________School Assistance Team
________PEP
________ESOL Services
________Other
EC Eligibility Yes/No (circle), if so:
EC Area of Eligibility
IEP Review Date
Level of Service
Reeval Due Date _________
504 Yes/No (circle), if so:
504 Plan Reason
Review Date
Is student currently under suspension?
If yes, list the reason(s), the duration and
the dates:
________________________________________________________________________
______________________________________________________________________________
Number of Suspension (ISS, OSS, ALC) during current school year, Please include the dates of
discipline referrals. : _____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Is the student currently in SCALE? _______If so, how many days? _______________________
Revised 9/20/13
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Data Needed (Please bring the following documents to the Crescent Academy meeting.):
Behavior Summary (Powerschool)
School Discipline Referrals
Review of attendance records for the last two school years (Excused vs. Unexcused, explanation
of particular circumstances, pattern of absences, etc.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Attendance Reports
Describe the reason(s) for the referral (attach additional pages if needed): Please be specific
with the types of behaviors seen including their duration and frequency.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Additional Information:
Parents (phone calls, conferences, referrals to other agencies)
Medical Concerns (mental health diagnosis, medications, accommodations/interventions, history,
affect on school, etc.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Other Relevant Information
Revised 9/20/13
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Specific Interventions Prior to the referral: Please specify which interventions were used, the
frequency and the outcomes. Interventions are listed in categories. Please bring documentation to the
Crescent Academy referral meeting.
Academic (scheduling, tutoring, mentor, modifications/accommodations, etc.)
Data Needed (Please bring the following documents/information to the Crescent Academy
meeting. All of the documents/information listed below will not be relevant to every student. If
that is the case, please write N/A in the box.):
Progress Reports
Cumulative Folder
Report Cards
EC Folder
PEP
Class Work Samples
Retention Information
Direction Instruction
Information (results and
progress)
Brigance Data/Reading
3D/AIMSWeb
Behavior (behavior contract, counseling, patterns of behavior, specify intensity, duration,
frequency of behavior, etc.)
BIP Review Date (s)_____________
Data Needed:
FBA/BIP and Results
Copies of Behavior Plans
Observation Logs
Social (counseling-school-based or community based, referral to support services personnel,
mentor, peer support, social skills programs/strategies, etc.)
Data Needed (Please bring the following documents/information to the APEX meeting. All of
the documents/information listed below will not be relevant to every student. If that is the case,
please write N/A in the box.):
Social Skills Strategies
and Progress Information
Therapy Logs
Revised 9/20/13
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Outside Agency Involvement (DJJ, DSS, Mental Health Services- Please include length of
involvement, the length and duration of services if known, contact information for agency,
psychiatric residential facility or group home information, in-home therapy, day treatment
services, court involvement, involvement of Behavior Specialist/Social Workers and their
supporting data):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Data Needed (If applicable):
Agency Contact Information
Referral Application completed by
(Signature and Date)
Principal’s Signature
Revised 9/20/13
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