Form JB-4
Office Use Only
Date: Received: _______________
Empowering dreams for the future
School Social Worker
2015-2016
Referral Form
First Contact: ________________
Referral Date:
Date of Birth:
Student Name:
School:
Teacher:
Grade:
Demographic Information (complete below or attach Profile Page from On Track/CSIS)
Parent(s) Name:
Address:
Street
Apt.
City
Zip
Email Address:
Phone:
Home
Cell
Work
Attempts made by school to alleviate problem before referring to SSW (Required)
Date
Call
Letter
Conference
Outcome
Teacher
Administrator
REASON FOR REFERRAL: (attach correspondence)
CASE CATEGORY: (check all that apply)
Academic
Out of District
Attendance/Dropout**
Discipline
Group
Abuse (home alone)
Special Education
Family (includes: Economic Aid, Health, Glasses, Social/Emotional, Personal, Substance abuse)
**For attendance referrals, PPO must indicate in CSIS Notes: “(Date) student was referred to SSW for attendance concerns”
Referring Person’s Signature
Admin Signature
Please mark all dates of absences below (Mark according to Legend) Attach Printout
LEGEND
3
10
17
24
31
-Student Holiday
T – Tardy
X – Unexcused Absence
(X) – Excused Absence
E – Entry RE - Re-entry
WD – Withdrawal
2
9
16
23
30
7
14
21
28
NOVEMBER
3
4
5
10
11
12
17
18
19
24
25
26
1
8
15
22
29
MARCH
2
9
16
23
30
3
10
17
24
31
6
13
20
27
4
11
18
25
7/27/15: School Social Work
7
14
21
28
4
11
18
25
AUGUST
4
5
6
11 12
13
18
19
20
25
26
27
DECEMBER
1
2
3
8
9
10
15
16
17
22
23
24
29
30
31
APRIL
5
12
19
26
6
13
20
27
7
14
21
28
7
14
21
28
4
11
18
25
1
8
15
22
29
7
14
21
28
SEPTEMBER
1
2
3
8
9
10
15
16
17
22
23
24
29
30
JANUARY
4
11
18
25
5
12
19
26
2
9
16
23
30
3
10
17
24
31
*JB-4*
6
13
20
27
MAY
4
11
18
25
(REQUIRED)
OCTOBER
4
11
18
25
7
14
21
28
1
8
15
22
29
5
12
19
26
6
13
20
27
5
12
19
26
1
8
15
22
29
1
6
7
8
13
14
15
20
21
22
27
28
29
FEBRUARY
2
3
4
9
10
11
16
17
18
23
24
25
2
9
16
23
30
5
12
19
26
Number of Days Student
was absent last year:
*Unsigned or incomplete
forms will be returned
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