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School Professional Referral Form
Referral Date:
Please provide the month, day, and year in 2 digits, 2 digits, and 4 digits respectively
Youth's School:
This field is required
Grade Level
K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
This field is required
Youth's Name:
This field is required
Date of Birth:
Please provide the month, day, and year in 2 digits, 2 digits, and 4 digits respectively
Please check any of the following issues that apply:
Peer Conflict
Attendance
Academic Performance
Expulsion
Behavioral Referrals
Mental Health
Family
Running Away
Gang Involvement
Substance Use
BCOP (Beyond Control of Parent)
Suspensions
Violence/Aggression
Other
Please select at least one option
Parent/Guardian Name:
This field is required
Relation to Youth:
This field is required
Address:
This field is required
Phone Number:
Format must be 123-123-1234. This field is required.
Email:
Please provide a valid email address
Language(s) Youth Speaks:
This field is required
Language(s) Parent(s) Speak
This field is required
Does the Student have an IEP or 504 Plan?
Yes
No
Please select at least one option
If yes, please specify which plan:
IEP or 504
Does your child receive services at school?
Yes
No
Please select at least one option
If yes, please specify services received:
Is student involved in truancy court?
Yes
No
Please select at least one option
If yes, please specify which court:
Was the parent notified of referral to LaMARC?
Yes
No
Please select at least one option
If yes, please specify:
Is DCFS or OJJ involved with the youth?
Yes
No
Please select at least one option
If yes, please specify:
Additional Comments or Concerns:
Referring Professional:
This field is required
Referring Professional Title:
This field is required
Referring Entity:
This field is required
Please list school-based services offered prior to the referral :
This field is required
Phone:
Format must be 123-123-1234. This field is required.
Email:
Please provide a valid email address
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