Burchell High School Counselor Referral Form
Directions: Please fill out this form when you are referring a student to either the Summit of ABLE program at Burchell:
               Summit: is for 9th-12th graders (to include credit deficient 9th and 10th graders)
               ABLE: for 11th and 12th graders that are credit deficient 
**Please fill out the application with the student/family or refer them to do so**
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Referring Counselor *
Student's First and Last Name *
What grade is the student in? *
What program are you referring the student to? *
Is daily attendance an issue for this student? *
Does the student have a 504 or IEP?
                          OR 
Are they in the referral process for either?
*
Is the student classified as FIT or are they acting as their own adult? *
Do you have academic, behavior, or mental health concerns for this student? Please provide as much detail as possible. *
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