REFERRAL FORM for CONSIDERATION of R.I.S.E. (Reaching Independence Through Structured Education)

R.I.S.E. Program 1315 South Broadway New Ulm, MN 56073 ph(507) 359-8760 fax (507) 359-1380 Doug Hazen, Coordinator

REFERRAL FORM for CONSIDERATION of R.I.S.E. (Reaching Independence through Structured Education) PROGRAM

The R.I.S.E Program is for ASD or DCD students. This program serves students, K-12, who need individualized environments, academic and/or functional skill development, and behavioral support.

Date:______

Student’s Name:______Grade:______Date of Birth:______Referring District: ______Contact Person ______Phone: ______Is the student receiving ASD or DCD services at least 21-60% of their school day? ______Has the River Bend Special Education Coordinator observed/consulted with the special education case manager concerning this child?______

Identify the concerns and problems that the student has been encountering: ______List any medication currently and previously taken by the student. Include name of medication, amount prescribed, how often taken, etc. ______Academic strengths of the student: ______Academic challenges and needs of the student. ______Academic Achievement Levels (Ex: Reading: 5.2, etc.) Reading:______Math:______Written Expression:______Student’s Full-Scale IQ: ______

Social/Behavioral Strengths: ______Needs: ______

Motor Needs ______Social History

Family structure (parent, stepparent, siblings, adoption, etc): Issues or concerns to be aware of: ______School history (including concerns or areas of difficulty): ______Medical history (serious illness or current health issues): ______Contact information from anyone involved with mental health history:

______Legal issues (CHIPS, delinquency, out-of-home placement, drug issues, etc.) ______River Bend R.I.S.E. Program 1315 South Broadway New Ulm, MN 56073 ph(507) 359-8760 fax (507) 359-1380 Doug Hazen, Coordinator

Health Information

Student: ______DOB: ______Address: ______Grade: ______Sex: ______Home Phone: ______Mother’s Name: ______Mother’s Work Number: ______Mother’s Address: ______Mother’s Cell Phone: ______Father’s Name: ______Father’s Work Phone: ______Father’s Address:______Father’s Cell Phone: ______Parent Authorized Designee to p/u student if parents are unavailable: Names: Phone Numbers: ______Present Health Status of Student ____ Good – No adaptations needed ____ Has a chronic illness or disability Name of chronic illness or disability: ______Medication or Treatment: ______Has allergies Treatment: ______

Physician’s Name: ______Phone # ______Address: ______

Parent/Guardian Signature: ______Date: ______River Bend R.I.S.E. Program 1315 South Broadway New Ulm, MN 56073 ph(507) 359-8760 fax (507) 359-1380 Doug Hazen, Coordinator

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

Client Name: ______Date of Birth ______I authorize River Bend to ___ Exchange with or ____Disclose To or _____Obtain From: ______Name of Organization & Individual ______Mailing Address ______City/State/Zip: ______Telephone # ______Fax ______

The information is necessary for the following purpose: _____ Evaluation/Treatment ____ Other ______

Information to be released (circle Yes or No) Yes No Evaluations, notes/summaries including Psychiatric, Psychological, Medical, Chemical Dependency Yes No Service date Yes No Court/Corrections Information Yes No School or Educational Information (may include academic progress, behavior issues, special education data) Yes No Social Services Agency Information Yes No Other (specify) ______

I UNDERSTAND THAT: * This information may include chemical dependency information * I have the right to revoke this authorization at any time by given written notice to River Bend Education District. I understand that the revocation will not apply: 1: to information that has already been released in response to this authorization or 2: to my insurance company as the law provides my insurer with the right to contest a claim under my policy. * I need not sign this authorization to receive services unless the services are court-ordered or are being created solely for a third party (i.e., consultation) * River Bend can not prevent the re-disclosure of records released as a result of this request and that after release from River Bend, the records may not be subject to privacy rule protections. * This authorization will permit two-way telephone communication and exchange of information by electronic methods. * I’m entitled to a copy of this authorization once I have signed it and I may review/request copies of information disclosed. * A photograph or facsimile of this authorization is as effective as the original.

This authorization shall remain in effect until this date: ______(one year maximum)

______Client Signature Date Witness Signature Date

______Parent/Guardian Signature Relationship to Client Date ------A copy of this authorization to obtain information was sent to the above agency on (date) ______by ______Signature Date Signed: Date Expires: Entered By