Healthy Start FRC Referral Form

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400 E Hermosa St, Lindsay, CA 93247/Phone - (559) 562-8292; Fax - (559) 562-8008

Email *

Learner Child's Full Legal Name- please match it to Aeries *

Referring Party (Full Name) *

What is your relationship to child?
*

Referring Party Contact Number *

Date of birth of Learner *

YYYY

Age of Learner *

Student ID Number *

Phone Number *

Father's Name *

Father's Date of Birth *

Mother's Name *

Mother's Date of Birth *

Language *

Spanish

English

Other:

If child lives with a parent please indicate which one: *

Father

Mother

Both

Caretaker/Guardian

Caretaker/Guardian Name *

If different than Parent's listed above.

Home Address *

Include Address, City, Zip Code

School Attending *

Grade *

Learning Facilitator *

Reason for Referral (Breakdown) *

Check all that apply

Basic Needs (Food/Clothing)

Healthcare

Psychological/Mental Health (TYSB Referral)

McKinney Vento

Pregnant

COVID - Hardship

Foster Child

SafeCare/Parenting Wisely

Education - Preschool/Special Ed Support

Parenting Skills

Finances

Known or suspected substance abuse

Pregnant Teen/Teen Parent

Case Management

Aggressive Behavior/Defiant

Family Services Referral

Housing

SARB/Expulsion

Domestic Violence

Immigration

Paperwork/Applications

Resource Linkage

Depression/Disorders/Anxiety

Other:

Required

Reason for Referral (please be detailed) *

Does this learner have siblings/children that need to be served? If yes, provide their name, DOB, ethnicity, gender, grade, school and sped services.

MTSS Level: What level of support does this child need?
*

Tier 1: Universal Strategies including Behavioral, Academic, SEL, College and Career

Tier 2: Targeted Interventions: CICO, Mentoring, Restorative Circles, etc

Tier 3: Intensive, Individualized Interventions: Behavior/Safety plan, Counseling, Suicide, etc.

Not Sure

Required

Please indicate below whether the site or district attempted Tier I or II interventions for this learner/family before completing this referral (e.g. SST meetings, home visits, parent/caregiver meetings) You will be asked to detail interventions later in the form *

Yes, Interventions have been attempted

No, Interventions have not been attempted

Unsure

Other:

Please check the interventions tried, check all the apply: *

Behavior Chart/Contract

Breaks: in class movement breaks, errand break, etc.

Check in, Check out

Consequences: parent called, recess academy, etc.

Filed a SCAR (Suspected Child Abuse Report)

Home Visits, successful (made positive contact with parent/guardian

Home Visit, unsuccessful (no answer, left card, etc)

Incentives: call parent, send home a positive note

Lifelong learning mentor support

SST or other school meeting support

Referral to SRO

Relationship building: praise, community circles

Not sure

Other:

Required

Is the Learner receiving any special education services ( IEP, 504 Services)? *

Yes

Not Sure

If you are requesting mental health support, please describe what symptoms or behavior you are seeing that are tied to the MH disorder:

Anger or Anger Mgmt support needed

Anxiety

Child Abuse

Depression

Drug or Alcohol use

Grief/Loss

Parent Child Issues

Post Partum Depression

Sexual Abuse

Suicidal Ideation

Trauma Related Support needed

Violence Perpetrator

Violence Viction

Other:

If a TYSB request is required, has it been submitted to TYSB? Please send a copy of the referral to us. *

Does this case warrant it to be expedited for services? If so why? *

Goal of the referring party? *

What do you hope Healthy Start can do to help this child and their family? Please be specific.

A copy of your responses will be emailed to the address you provided.

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