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RCPS Behavioral Intervention Referral Form
To Be Completed By Referral Source or School Counselor
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* Indicates required question
Referral date:
*
Your answer
Student name:
*
Your answer
Student’s RCPS ID#:
Your answer
Gender:
*
Female
Male
Other:
Ethnicity:
*
Your answer
School:
*
Your answer
Grade:
*
Your answer
Birth date:
*
MM
/
DD
/
YYYY
Age:
*
Your answer
Student address:
*
Your answer
Zip:
*
Your answer
Parent/Guardian name(s):
*
Your answer
Home phone:
Your answer
Cell phone:
*
Your answer
Work phone:
Your answer
Custodial Rights:
*
Mother
Father
Both
Guardian
State Agency
Other
Does the student have a current IEP?
*
Yes
No
If yes, Case Manager name:
Your answer
Consultant name:
Your answer
Does the student have a Section 504 Plan?
*
Yes
No
Does the student and/or parent/guardian require an interpreter?
*
Yes
No
If yes, what language:
Your answer
Who is making this referral?: (Name)
*
Your answer
Referrer is a:
*
School Counselor
Administrator
School Social Worker
Psychologist
Other:
Referral source’s phone #:
*
Your answer
Referral source’s email:
*
Your answer
To which School Counselor is this student assigned?
*
Your answer
School Counselor Phone #:
*
Your answer
School Counselor Email:
*
Your answer
Has this student been staffed with your school’s RTI/SST/AST?
*
Yes
No
Date case was staffed or will be staffed (if applicable):
*
MM
/
DD
/
YYYY
In addition to this referral, please check any previous actions that have taken place in regard to this student?
*
Individual Counseling
Group Counseling
Family Counseling
ISS
OSS
CHOICES
Alpha Academy
Fresh Start
DJJ
Probation
Previous Hospitalization
Drug Abuse Intervention
Attendance Plan
Behavior Contract
Gang Contract
Current Medication
Behavioral Screening
Evaluation
P&I Specialist Involvement
Other Support Services
Required
Does this student exhibit any of the following warning signs for at-risk behaviors? Early Warning Signs (low-to-medium-risk factors/behaviors)
*
Social withdrawal
Poor social skills
Excessive feelings of isolation and of being alone
Excessive feelings of rejection
Feelings of being picked on and persecuted
Persistent sadness
Impulsive behavior
Violent and/oraggressive behavior
Uncontrolled anger
Chronic disruptive behavior
Bullying
Stealing
Homeless
Intolerance for differences/prejudicial attitudes
Low school interest/poor academic performance
Excessive absences/Truancy
Affiliation with gangs
Drug use and/or alcohol use
Expression of violence in writing and drawings
Access to, possessionof, and use of weapons
Recent loss, grief
Serious medical illness/traumatic injury
Legal Issues
Family Issues
Lying/Manipulative behavior
Other:
Required
Imminent Warning Signs (high-risk factors/behaviors)
*
Serious physical fighting
Detailed threats of lethal violence
Possession and/or use of firearms, other weapons
Severe destruction of property
Child Abuse & Neglect (CAN)
Setting fires
Severe rage for seemingly minor reasons
Sexually aggressive behavior
Other self-injurious behaviors or threats of suicide
Sexualized behaviors
Other:
Required
What prompted this referral? What are your concerns about risk? Any additional comments you would like to include?
*
Your answer
Has the family been notified that a referral for behavioral interventions has been made?
*
Yes
No
Name of family member contacted:
*
Your answer
Has family member signed Consent for Behavioral Health Screening and/or services?
*
Yes
No
OTHER PROFESSIONALS INVOLVED WITH STUDENT
*
Yes
No
Child Welfare Services
Mental Health Provider
Physical Health Provider
Juvenile Court
DJJ
Yes
No
Child Welfare Services
Mental Health Provider
Physical Health Provider
Juvenile Court
DJJ
For each yes, enter corresponding information below. (Names, Agencies, Phone Numbers)
Your answer
SERVICES RECOMMENDED/REFERED:
*
Screening
P&I Services
SBMH Services
CBMH/AD Services
Counselor
Required
If School-Based MH Services recommended, who will contact AFE with referral information? (Name, Title, Phone Number)
Your answer
I verify and acknowledge that I have reviewed all of the information contained in this document. (Full Name)
*
Your answer
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