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Hesperian COST Referral
Before submitting referral, interventions and family contact must be attempted when appropriate.
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* Indicates required question
Email
*
Your email
Referred By (your name)
*
Your answer
Your Email (if you want an email confirmation of your submission)
Your answer
Student's Name
*
Your answer
Grade Level
*
Choose
Preschool
TK
Kindergarten
1
2
3
4
5
Crisis/Emergency
*
Is this a situation that needs attention immediately or within 24 hours (e.g. death in family, suicidal ideation)?
Yes - Please CALL the school administrator IMMEDIATELY
No
IEP
*
Does this student receive special education services?
Choose
Yes
No
Unknown
Student Strengths and Interests
Your answer
Social/Emotional/Behavioral Concerns
Disrespectful or Non-Compliant Behavior
Repeated Absences and/or Tardies
Frequent Conflict and/or Fighting
Socially Withdrawn
Limited Social Skills
Home and/or Family Concerns
Physical/Medical Concerns (sleep, medication, etc.)
Possible Depression Symptoms
Possible Substance Use
Possible Abuse (checking this box does not fulfill mandated reporting duty)
Possible Gang Involvement
Sexual or Gender Identity Concerns
Other:
Academic Concerns
Reading
Writing
Mathematics
Speech and Language
Organization Skills
Sudden Change in Academic Performance
Not Using Class Time Well
Not Earning Full Credit
Lack of Motivation and/or Effort
Other:
Relevant Scores (NWEA, F&P, etc.)
Your answer
Please describe concerns or incidents that you have observed:
Your answer
Previous Interventions
Please check all that apply:
Academic Support (e.g. tutoring, reading intervention, etc.)
Phone Call Home
Talked with Student
Family Conference
Office Referral
Prior Referral to Counselor
Other:
Outcomes
Please describe previous interventions and the outcomes of these:
Your answer
What interventions do you think could help?
*
Please check all that apply:
SST (Student Study Team)
Therapy Referral
Restorative Circle or Mediation
BAT (Behavior Assistance Team)
Family Meeting
School Counselor Check In
Referral to Community Resources or Family Liaisons
Internal Staff Consultation or IRT Meeting
Other:
Required
Thank You!
A COST member will email you an update in response to your referral.
A copy of your responses will be emailed to the address you provided.
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