Rochester Independent School District #535

ROCHESTER INDEPENDENT SCHOOL DISTRICT #535 TRANSITION LEARNING CENTER (TLC) PROGRAM

REFERRAL FORM

Date of Referral:

STUDENT INFORMATION

Name of Student: Date of Birth: Student ID#: Student Address: Parent/Guardian Name: Parent/Guardian Address: Home Phone #: Work Phone #: Email: Cell Phone:

SCHOOL & COMMUNITY INFORMATION:

Referring Case Manager: Work Phone: Referring School: IEP Related Services:

PRIMARY DISABILITY (Indicate P) SECONDARY DISABILITY (Indicate S) EBD Autism DCD PHD LD Vision DHH Speech/Language

RELATED SERVICES OT PT DAPE

INFORMATION REQUIRED FOR REFERRAL (Please attach to referral form) 1. Individual Education Plan (IEP) (Include Behavior Intervention Plan) 2. Current Evaluation Report (Completed the year of referring to program) 3. Medical Information (if appropriate), Include Emergency Health Care Plan 4. Residential Program Plan (if appropriate) 5. Vocational Experience Reports/Evaluations

COUNTY SOCIAL WORKER: Yes No Applied for If yes, Name: Phone #: Email: LEGAL GUARDIAN: Yes No Applied for If yes, Name: Phone #: Email:

IN-HOME RESIDENTIAL SERVICES: Yes No If yes, Name: Phone #: Email:

GROUP/FOSTER PLACEMENT: Applied for If yes, Name of Group Foster Home: Address of Group Foster Home: Phone #: Group/Foster Home Contact Person: Phone #: Email:

State ID: Yes No Applied for If yes, does the student carry it with them? Yes No

Library Card: Yes No Applied for If yes, does the student carry it with them? Yes No

ZIPS certified: : Yes No Applied for If yes, does the student carry it with them? Yes No

SSI/SSDI: Yes No Applied for

EXTRA CURRICULAR INVOLVEMENT

RADAR: Yes No If yes, If yes, comment:

Park & Recreation Department: Yes No If yes, If yes, comment:

Rochester Family Y/Rec Center/RAC (other): Yes No If yes, If yes, comment: Community Education: Yes No If yes, If yes, comment:

Rehabilitation Services: Yes No If yes, If yes, comment:

Work Force Center: Yes No If yes, If yes, comment:

ABC/PossAbilities: Yes No If yes, If yes, comment:

Assistive Technology (PACTT): Yes No If yes, If yes, comment:

VOLUNTEER INVOLVEMENT Please describe any volunteer activities that the student has been active in (on or off campus):

WORK EXPERIENCE INVOLVEMENT Has the student/family toured: Edison Work Site: Yes No In Process ESC Work Site: Yes No In Process ABC: Yes No In Process

If yes, which sites?

PossAbilities: Yes No In Process

If yes, which sites?

Please describe any work experience activities that the student has been active in (on or off campus):

AREAS OF STRENGTH (Please check all those that apply to the student)

Listens Follows instructions Attendance Completes assignments Sets goals Stays on task Expresses feelings Understands other’s feelings Deals with anger constructively Accepts consequences Solves problems Interested in learning Shares ideas Asks for help Works cooperatively Gets along well with peers Gets along well with adults Accepts responsibility for own behavior Uses self control Stays out of fights Passing grades Sports Gifted academic performance Communication skills Honesty Written expression Other: INTERESTS Sports Playing musical instrument Bowling Singing Computers Listening to music Watching TV Games Other:

CURRENT BEHAVIORAL ASSESSMENT INFORMATION Is there a BIP? Yes No

Date: What behavioral interventions have been successful?

Physical restraint? Yes No

Frequency: Positive interventions and effectiveness: Incentives: Time Out:

MENTAL HEALTH HISTORY History of self-injurious behavior: Yes No Explain: History of attention inattentiveness: Yes No Explain: Difficulty with peer relationships: Yes No Explain: History of sexual inappropriateness: Yes No Explain:

PHYSICAL HEALTH

Are medications administered at school? Yes No Explain: Describe any health concerns: Yes No Seizures Yes No Allergies Yes No Asthma Yes No Vision Concerns Yes No Hearing Concerns Yes No Previous Serious Persistent Illness

ANY ADDITIONAL INFORMATION? Please describe any additional information that may be beneficial for the intake team to know:

Student Signature: Date: Parent Guardian Signature: Date: IEP Case Manager Signature: Date:

SEND COMPLETED FORM TO STUDENT SUPPORT SERVICES SUPERVISOR AT ESC