School Professional Referral Form

Referral Date Format: mm/dd/yyyy

Youth's School

Grade Level

Youth's Name

Date of Birth Format: mm/dd/yyyy

Please check any of the following issues that apply:

Parent/Guardian Name

Relation to Youth

Phone

Address

Language(s) Youth Speaks

Language(s) Parent(s) Speak

Does the Student have an IEP or 504 Plan?

Yes No

If yes, please specify which plan IEP or 504

Does your child receive services at school?

Yes No

If yes, please specify services received

Is student involved in truancy court?

Yes No

If yes, please specify which court

Was the parent notified of referral to LaMARC?

Yes No

If yes, please specify

Is DCFS or OJJ involved with the youth?

Yes No

If yes, please specify

Additional Comments or Concerns

Referring Professional

Referring Professional Title

Referring Entity

Please list school-based services offered prior to the referral

Phone