Updated: December 4, 2014

Summit Ridge Academy Referral Form

Program student is being referred to:

STUDENT INFORMATION SECTION: Referring School: Date of Request: Date of Interview: Student Name: Student ID#: Age: Date of Birth: Guardian Name: Relationship to Student: Grade: Home Phone: Work Phone: Cell Phone:

SCHOOL GUIDANCE COUNSELOR SECTION: Have you consulted with the student and parent about this referral? Is the student on an IEP?

If yes, have you contacted your Special Education Process Coordinator? Is the student on a 504?

If yes, please list specific concerns for the student as stated in the 504?

If yes, have you contacted your Special Education Process Coordinator? Has the student been referred to SAP Team?

If yes, please specific the programs and interventions: Has the student been in an At-Risk Program or other RTI in your building? If yes, please specify the program and interventions: What are the student’s current Locator Test Scores (within 1 Semester of the referral):

Reading Math: Language: Date:

Note: The Locator Test is available through your lead counselor in the building.

If a high school student scores below 6.5 grade level in Reading and Math, please consider other options.

If a middle school student scores below 5 grade level in Reading and Math, please consider other options. Does the student have any medical conditions that we need to be aware of?

If yes, please attach the necessary information. Is the student currently assigned to a DJO, PO, or DFS caseworker?

If yes, what is his/her name: Phone No.: Please list the school(s) and year(s) the student has attended in the last three years: If the student is coming from another school district and the student’s transcript is not updated in PowerSchool yet,

please attach a copy of the student’s transcript. Select from the below student profiles. NOTES: Please select all the profiles that apply to this student.

Chronic absenteeism/truancy At-risk of dropping out

Chronic academic performance Long-term suspension

Chronic discipline referrals District Level Assignment

Coming from an alternative program out of district Other:

Retained one or more academic grade levels (middle school only)

Please select the profile that you believe is the greatest concern:

Please continue on the next page.

Updated: December 4, 2014

CONTINUATION – SCHOOL GUIDANCE COUNSELOR SECTION:

How long does this student plan to attend SRA? Please state the transition by semesters:

Please add any additional comments and/or concerns that you believe will help us serve the needs of this student:

Counselor Name:

Please email this referral form to your identified Building Referring Administrator.

NOTE: If this student is on an IEP/504, please email this referral to the building Special Education Process Coordinator.

BUILDING SPECIAL EDUCATION/504 PROCESS COORDINATOR SECTION:

Have all the IDEA procedural safeguards been addressed for this student:

Please add any additional comments and/or concerns that you believe will help us serve the needs of this student?

Please email this referral form to your identified Building Referring Administrator.

Please attach a copy of the IEP to the referral.

Please attach a copy of the 504 to the referral.

BUILDING REFERRING ADMINISTRATOR SECTION:

Please add any additional comments and/or concerns that you believe will help us serve the needs of this student:

Building Referring Administrator Name:

Please email this referral form to your identified Building Referring Administrator.

Is the student currently on probation for a long-term suspension?

If YES, please attach copies of the following:

- The superintendent’s letter documenting the suspension

- The enrollment letter to a substance abuse counseling program (if applicable)

- Any progress reports from the substance abuse counseling program (if applicable)

NOTE: If this student is in need of a district level assignment, please email this referral form to the Assistant

Superintendent for Secondary Instruction.

NOTE: If this student is on an IEP, please email this referral form to the Executive Director of Special Services.

REFERRING DISTRICT ADMINISTRATOR SECTION:

How long will this student be required/expected to attend SRA? Please state the transition by semesters:

Please add any additional comments and/or concerns that you believe will help us serve the needs of this student:

Referring District Administrator Name:

Please email this referral form to the SRA Principal Secretary and SRA Principal.