Step-by-Step to complete New Student Referral Form

Owned by Meaghen Spencer (Unlicensed)
Last updated: Aug 24, 2022
5 min read

 

Student Referral Form

click on the Form to enlarge

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 as collected by the coordinator during intake.

 

 

 

CPS Involved

Indicates if the student is involved with CPS.

 

Organization

(required field): Select the service provider’s name from the dropdown menu. 

 

  1. 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”.

  2. 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, separate referrals should be added to a student’s profile/case, even if the separate service is provided by the same organization. 

 

 

 

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. . Only Mental/Behavioral health referrals will involve a program.

 

 

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.

  • For example, a student that is “Referred to Services”, but is not yet confirmed to be linked to services would still be 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

The goal over the school year and at the end of the school year is to assign all students to an inactive, closed status for each referral. This will be achieved by following up with parents and teachers and providers, as appropriate.

To Close a referral, the coordinator must select an Inactive status and select the Date the referral was closed.

insert Inactive/Close definitions

 

Date Closed: Once 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

 

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