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2023-24 Lincoln Alternative Academy Counselor Referral
School Counselors - Please complete this student referral form for a student to be considered for enrollment at Lincoln Academy.
Please understand that filling out this form does not guarantee acceptance into Lincoln Academy.
All responses will be kept confidential and be used as part of the intake / screening process for student enrollment at Lincoln Alternative Academy. Thank you!
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* Indicates required question
Email
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Your email
Student Last Name
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Your answer
Student First Name
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Your answer
Today's Date
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MM
/
DD
/
YYYY
Grade
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9th
10th
11th
12th
Required
Referring School
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Your answer
Referring Counselor
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Birdwell
Brien
Morton
Swanson
White
Hayes
Co-Op School
Becker
Other:
Required
Have you visited with your site administration about submitting this referral and are they supportive of the recommendation? If not, please visit with them first before submitting. Thanks!
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Yes
No
If you answered Co-op school above, please list the school and referring counselor
Your answer
If the student is new to Stillwater and is requesting a referral to be considered at Lincoln Academy, where did the student last attend school? (city, state, and name of the school).
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Age?
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Your answer
Please list the student's current GPA.
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Your answer
Credit Deficiency according to cohort class.
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2 credits of less
3-5 credits behind
6-8 credits behind
8 or more credits behind
Student is not behind on credits.
Other:
Has the student completed the state mandated CPR training?
Yes
No
Clear selection
If you marked "Yes" on the previous question regarding CPR training, please list the date it was completed.
Your answer
Behavior Interventions
Closed Campus / Detention
In School Placement (ISP)
Out of School Placement (OSP)
N / A
Other
If you listed "Other" above, please share information.
Your answer
Attendance - Previous Semester
*
Absent Less than 10 days
Absent More than 10 days
Absent More than 20 days
Other:
Please list the main reasons for the student's absences?
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Your answer
Please share the student's main reason for wanting to attend Lincoln Academy.
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Your answer
Please check the following criteria that applies to the student which should be considered for enrollment at Lincoln Alternative Academy.
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Academic - Behind on Credits
Absences from School
Behavior Difficulties
Family Issues
Pregnant or Parenting
Involvement with the Court System
Financial Issues
Health Issues
Mental Issues
Substance Abuse - Drugs or Alcohol
Involvement with Juvenile Justice - OJA, probation, etc.
DHS Custody
Dropout - Seeking to get back into school
Transience from school
Other:
Required
If you marked "Other" on the previous question, please explain.
Your answer
Please check the following state or federal programs that support this student?
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IEP
OHI
504
ELL
506
N/A
Required
If you answered yes to being on an IEP, what areas of support did the student receive (Math, Reading, Behavior, etc.)?
Your answer
If you answered yes to any other state or federal programs, please share information to describe and support provided.
Your answer
How long has the student been at your school site?
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Student is new to Stillwater
Less than 1 month
One Semester
One Year
More than a Year
Has a behavioral intervention plan been implemented?
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Yes
No
Required
Have counseling services been implemented?
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Yes
No
If you answered yes to counseling services, please share information. (Counselor / Agency & Frequency)
Your answer
Please share any other relevant information you feel we should know about this student as they're being considered for enrollment at Lincoln Academy? Thank you for your time!
*
Your answer
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