High School To Community Transition Program Referral
Case Managers to Complete questions 1-26   (***section at the end to complete with students, questions 27-35***)
Email *
1. Student's name in Synergy *
2. Pronouns, preferred names.  *
3. Student ID # *
4. Is the student on track to graduate? *
5. Case Manager's name *
6. Please select the most appropriate answer regarding the student's plans re: CTP *
Required
7. Home address: *
8. Current School *
Required
9. Is the student his/her own legal guardian. *
Required
10. Eligibility Category *
Required
11. What program/level of support is needed in high school? (i.e. is the student spending all day in a restrictive environment, or just part time, such as ISC 4 periods, gen ed with para support 4 periods, or all day in SES, LC, reduced day, etc.): *
12. Are interpretation services needed?  *
Required
13. What languages are spoken in the home? *
14. What about school is challenging for the student? What should we know? *
15. Which strategies are helpful? *
16. Please list anything we should avoid for this student (ways of communicating, activities, etc.). Write n/a if none. *
17. Please check any services the student has access to: *
Required
**If the student doesn't have DD but probably should (ID, Down Syndrome, ASD, Cerebral Palsy, Epilepsy, Fetal/Alcohol/Drug Effects, TBI)-here's a link for a referral  https://www.multco.us/dd/eligibility  PLEASE don't wait, refer students now!  
18. Tell us more about transportation. Please check ALL that apply. *
Required
19. Please list names and contact information for services here (ex: DD service coordinator). Write n/a if none. *
20. Please check any supports the student receives: *
Required
21. If PT listed on the IEP? Does the student have equipment? Does the student require additional help for accessing the environment (bathroom, buildings, etc.)? If none, please write n/a. *
22. If the student has personal care needs, please describe here. If not, please write n/a. *
23. If the student has adult assistance, please describe needs here (line of sight, needs help with transitions, etc). If none, please write n/a. *
24. Does this student have any technology (AT) that they use for communication? Please add who owns it (Personal, PPS or Columbia Regional, etc.).  If none, please write n/a. *
25. Other things we should know (i.e this student might move, this student isn't sure if they want to attend, the paper work is in progress for eligibility, this student has to have a blue worksheet to start their day, this student does not like____, etc. Does this student has a lot going on and needs someone from CTP to observe/check in?   If none, please write n/a. *
26. If the student has medication or medical concerns, please provide information here.  If none, please write n/a. *
27. Does the student have a history of self harm, intrusive unsafe thoughts, or suicide ideation/plan for suicide?  If so, please list any frequency or date information available.
(FOR THE FOLLOWING QUESTIONS--PLEASE COMPLETE WITH STUDENT -if they are able and willing to do so)  
28. I plan on attending the Community Transition Program *
29. Please tell us a little bit about yourself by checking the activities you can do independently, without support? *
Required
30. I need support to follow directions (choose one) *
31. I have completed a volunteer work experience or paid work experience? *
32. If you answered yes to the previous question, please tell us a little bit about that experience.
33. What words would you use to describe yourself (check any that apply) *
Required
34. I am very flexible and comfortable with new and changing situations. *
35. While attending the Community Transition Program, do you want our support to take some classes at PCC? *
36. Have you applied to FAFSA and if so have you received any grants that need to be used in Fall Term? (Such as Oregon Promise) *
Anything else you would like us to know? (Questions, concerns, other, etc.) 
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