Student Referral Form
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The first part of the Referral Form is the student profile which contains information about the student that is available from the SCCOE Student Data Warehouse and comes pre-populated. There are several other fields in this section that the SLS Coordinator fills out to complete the student profile.
These fields are pre-populated based on the school district’s Student Information System: Name, DOB (Date of Birth), School, Home Language, IEP, Homelessness, and Attendance %.
These fields must be populated by the coordinator: Sexual Orientation, Health Insurance, and CPS Involved.
Sexual Orientation
The student's self-reported sexual orientation.
Health Insurance
The student’s health insurance status.
CPS Involved
Indicates if the student is involved with CPS.
Organization
(required field): Select the service provider’s name from the dropdown menu.
Note: In some cases, an organization may not be listed in the global list. A coordinator can add a new organization by clicking on “add a new organization”.
However, please scroll through ALL organizations before you add a new organization.
Service
(required field): Select the type of service that the organization will be providing. For detailed information about the specific definitions (i.e. Tier I/ II/ III) for each service/category, see SLS Definitions. Only one service may be selected at a time. For a referral that includes more than one service, individual referrals should be added to a student’s profile/case.
Tier
When referring a student to Academic or Behavioral/Mental Health resources, the coordinator should identify the Tier of support which can range from 1 to 3.
Program
(required field): Select the program from the dropdown menu. Program refers to the various programs based on level of care from least intensive to intensive programs
Date Initiated
(required field): Date that the teacher, school administrator, other school staff, parent(s), self (depending on age) identified the service needed (i.e., the date recorded on the referral form provided to the coordinator).
Date Referred
(required field): Date that the coordinator first attempts to contact the family to make the referral. This date should not be before the date initiated.
Referred By
(required field): Role of person who provided the referral - teacher, school administrator (i.e. principal), academic counselor, therapist, parent liaison, nurse, parent, self.
Status
(required field): Select the status of the referral from the dropdown menu. There are two types of status: Active and Inactive.
After initiating a new student referral with outreach to the family and through successive follow-ups with the family, the coordinator is asked to select (and subsequently) update the status of the referral.
More about the Status
Active statuses are those that are still open.
Inactive statuses are referrals that are closed.
Inactive status may indicate negative results - such as “Unable to contact family”, or “Caregiver declined”.
However, there is an important positive inactive status - “Linked to Services”. This means that the Coordinator confirmed that the student or family received services or resources at least once.
Closing a Student Referral
**need to add language here what how does a coordinator close the referral.. the importance of “closing” a referral.
Date Closed: When an Inactive status is selected, a Date Closed selection will appear. Close date is the date on which the referral is closed. This option will only appear when an Inactive Status is selected in the App. Please ensure the Close Date falls after the Date Referred.
Specifications for Close Dates for each Inactive Status are outlined in the Service Link Variable Definitions
Reason for Referral
(required field) Indicates the cause for referral to be created. SLS coordinator can list multiple reasons. You may click on the overall Referral Reason or select a more specific reason by clicking on a sub-reason. For definitions about each of the Referral Reasons and Details, click here.
Coordinator Service
(required field) Identifies the type of services that were provided by the SLS Coordinator. Please check all Services that were provided to support that referral
Notes
(optional) The Notes section is available as an open text box where the SLS Coordinator can record any additional information important for case management. Please do not include Personally Identifiable Information (PII) this section.
When done completing the form, click