Ingham Intermediate School District
The Center for Career Preparation & Assessment
2014-2015
REFERRAL PROCEDURES
for
CAREER ASSESSMENT SERVICES
All Referrals Should Be Sent To:
Lindy Daman
CACC / Career Assessment Services
611 Hagadorn Road, Room 211
Mason, MI 48854
FAX: 517-676-3602
ATT: Lindy Daman
The following items must be completed with the referral form in order for a career assessment to
proceed. Dates for appointments cannot be held until all required documents are received: (please check
that each item is completed and/or attached)
□ Referral Form: (required)
□ Consent and Release of Information Form: (required)
The Consent and Release of Information Form authorizes Career Assessment Services to release information via
documented telephone conversation, fax or written form to the referral source and/or other designated individuals.
□ Individualized Education Program (IEP): (required) if special education eligible
A copy of the current IEP is required if receiving Special Education services. In addition, any background
information and social and/or medical history may be helpful as it allows the assessment staff to develop realistic
recommendations for the students.
□ Approximate Reading and Math grade levels: (required)
□ Educational Development Plan (EDP) password and/or Transcripts: (optional)
*Referral source needs to: contact bus garage to arrange transportation once an
appointment is scheduled.
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SE ________
RL ________
The Center for Career Preparation & Assessment
2014-2015 CAREER ASSESSMENT SERVICES REFERRAL FORM
(This form can be duplicated)
1.
STUDENT DATA:
Name:
Birthdate:
Age:
Address:
City:
Zip:
School:
Grade:
Gender:
Male
Female
Expected Graduation Date:
Home #:
Cell #:
Email:
2.
EMERGENCY CONTACT:
Name:
Relationship:
Please check the best method of contacting you.
3.
□
Home #:
□
Work #:
□
Email:
REFERRAL SOURCE:
Name:
Title/Position:
School:
Phone #:
Email:
Best Time to Call:
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4.
WHAT ARE YOUR EXPECTED OUTCOMES?
(Please check the service you would like the student to receive.)
Available Services
□ Comprehensive Career Assessment (Two half day sessions):
This is the traditional Comprehensive Career Assessment. Both sessions are held at the
Career Assessment Office located in the Capital Area Career Center. Arrangements may be
made for the first of the two half day sessions to be held on- site (at the students’ school) for
groups of six or more.
may include:
● Ability & Aptitude testing
● Personality
● Interest Surveys
● Work Values
● Learning Styles
● Updating EDP with assessment results
□ Career Assessment (One half day session)
This is a condensed version of the traditional Comprehensive Career Assessment. This is
appropriate for students not requiring the full Comprehensive Career Assessment, as outlined above. This one half day session is held at the Career Assessment Office located in the
Capital Area Career Center.
may include:
● Ability & Aptitude testing
● Interest Surveys
● Learning Styles or Work Values
□ Post-Secondary Planning (One half day session)
This service is appropriate for students seeking post-secondary planning services in a one-on-one
or small group setting. This service helps the student by using data generated from various
assessments to guide their decision making process. This one half day session is held at the Career
Assessment Office located in the Capital Area Career Center.
may include:
● College exploration
● Interest Surveys
● Take home guide for college planning
● Extensive resource guide
□ On-Site (at the students’ school) Group Services (based upon staff availability )
● Learning Styles
● Insight Personality
(referral form and consent not required for this service)
(referral form and consent not required for this service)
* Please call Lindy Daman, Career Assessment and Transition Coordinator, at 517. 244.1370 with
questions or to arrange on-site services.
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5.
EDUCATIONAL INFORMATION: (required) Include the approximate reading and math grade level in
which the student is presently functioning in order to determine the appropriate assessments to be used.
Reading
6.
Math
CURRENT INDIVIDUALIZED EDUCATION PLAN (IEP) INFORMATION:
Does the student receive Special Education services?
Primary Disability:
Yes
No
Previously
Secondary Disability:
If the student has a Learning Disability, please check all of the areas in which the student qualifies:
□
□
□
□
Listening Comprehension
Oral Expression
Written Expression
Mathematics Reasoning
□
□
□
Mathematics Calculation
Basic Reading Skill
Reading Comprehension
Does the student receive individualized para-pro support in the classroom?
If yes, a para-pro must attend all scheduled appointments
Yes
Has the student taken a Transition Assessment (ESTR, TPI, etc.)?
Yes
No
No
If yes please indicate which assessment was taken and date taken:
7.
ACCOMODATIONS NEEDED:
Please check all accommodations needed during the testing and assessment process:
□
□
□
□
□
□
□
8.
Extended time on tests
Reader
Use of a calculator
Redirect
Small groups
Reinforcement of appropriate behaviors
Assistance with writing or spelling
□
□
□
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Transportation considerations
Individual/ One-on-One
Decreased distractions
Frequent breaks
Directions in small steps
Speech/Language assistance
Para-professional assistance -If yes, a
para-pro must attend all scheduled
appointments
BEHAVIORAL OBSERVATIONS IN THE CLASSROOM:
Strengths:
Challenges:
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9.
WORK/SCHOOL INFORMATION:
Is this student behind in credits or ever been retained? Yes
No
List all Capital Area Career Center (CACC) Program(s) this student has expressed an interest in:
If enrolled at the CACC, what program?
10.
(AM or PM)
SCHEDULING:
I would prefer to have the students appointments scheduled in the:
AM
PM
Pre-assessments must be completed before their appointment.
11.
COMMENTS/ADDITIONAL INFORMATION:
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The Center for Career Preparation and Assessment
Career Assessment Services
Consent and Release of Information Form
I give my consent for _____________________________ to participate in the services provided by Career
Assessment Services. This information is best used to assist the student in transitioning past high school,
including identifying future career goals, related career and educational planning, and various adult living
skills.
I give permission for a digital photograph to be taken for identification purposes in their file for promotional
or informational materials. Parent/Guardian initials:
_______
Students completing a comprehensive career assessment will have a Career Planner Report sent to the
referral source, students, and parents/guardian upon completion of the assessment. For students
interested in Career and Technical Training Programs available through the Capital Area Career Center
(CACC), a copy of this report will be forwarded to the CACC enrollment coordinator, if requested.
Please note: Your student will not be scheduled for services provided by
Career Assessment Services without guardian consent.
Transportation must be coordinated by the referral source.
The Career Assessment Services office is located in Room 211 at the Capital Area Career Center (CACC), 611
Hagadorn Road, Mason, MI 48854.
For additional information you can contact:
Lindy Daman -
Career Assessment and Transition Coordinator
Parent/Guardian Signature:
ldaman@inghamisd.org
Date:
Address:
City:
517- 244-1370
Home Phone:
State:
Zip:
Work Phone:
□ Please send my student’s Career Planner Report by e-mail.
My e-mail address: ____________________________________________
This form must be returned to referral source:
*This authorization will expire upon graduation of the student.
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