McCreary Academy Referral
1. School Making Referral
MCHS
MCMS
Referral Type ( check all that apply)
PKIS
WCE
Academic
2. Student Identification Information
Name:
DOB:
Guardian 1:
Relationship:
Address:
Work #
Student lives with:
Both parents
One parent
Blended
Behavioral
Age:
Home #
Relatives
Emotional/Social
Grade:
Cell #
Guardian
3. Reason for referral:
Please check factors or characteristics that apply to this student:
Retained one or more years
Failed 2+ subjects (recent semester)
Sudden drop in grades
ESL
Exceptional Children’s status/category/disability______________________________
Excessive Absences/Tardies
Frequently skips class
Frequently leaves school early
Suspensions
Displays aggression, bullying, anti-social behavior
Displays inappropriate, attention-getting behavior
Involved in delinquent activities
Experience with bullying as victim
Withdrawn/Change in behavior
Lacks social skills; difficulty with peer relationships
Suspected gang involvement
History of abuse/neglect/dependency or domestic violence
Suspected alcohol, substance use/abuse
Pregnant/parenting
Health concerns___________________________________
Mental health concerns
Developmental issues
Family income too low to provide basic necessities
Sibling has dropped out of school or is teen parent
Prior or current DCBS referral
Frequent moves
CDW or Court or DJJ involvement
Homeless
Alternate #
Self
Friends
4. School Interventions attempted:
Social/Emotional
Parent conferences
Student conferences
Schedule change
School based counseling Person counseling:________________________________________________
Peer Advisor/Mentor/Buddy
YSC Referral
Home Visits
Academic
RTI Reading
Tier II or
Tier III Name of intervention specialist:_____________________________
RTI Math
Tier II or
Tier III Name of intervention specialist:_____________________________
Online Classes: ________________________
Exceptional Children
Special Education screen
Currently receiving special services
Behavioral
RTI Behavior
Tier II or
Tier III
School Behavior contract
Assigned to in-school suspension
Assigned to Alternative to Suspension
5. Referrals made for Community Interventions:
School charges filed against student? Charges:_________________________________________________________
DJJ probation or committed? Name of worker _________________________________________________________
DCBS referral
IMPACT Services
Outside counseling
Residential Treatment? Diagnosis:______________ Facility:______________________________ Dates:__________
Student Information: Check all that apply
Medication? Type:___________________________________
Medical conditions? Type:_____________________________
Suspected substance abuse?
Mental Health issues? Diagnosis:________________________
6. Necessary documentation if admitted to program :
Copies of past testing: KCCT, Explore, Plan, ACT, etc...
Cumulative Record/file folder with all mandated registration items.
Current IEP (if applicable)
7. Signature of School Administrator
Parent Notification of Referral
Date: __________By:___________________________