dropout prevention program referral form - … · web view1 transportation issues4 teen...

DIPLOMA ON!Referral Form

Name of person making referral:        Date of referral:      Date assigned to DOPP:      

Student InformationFirst Name:       ___________________________ Middle:       ______________ Last Name:      

Name of Resident District:       ________________________ Name of Current School:      

Date of Birth:      _______ _Student MARRS#:      ____________ Contact #/Email:      

Street Address:       _________________________________________ City:       Zip:      

Parent/Caregiver’s Name (if applicable):       ______________________ Contact #/Email:      

Probation Officer’s Name (if applicable):       ______________________ Contact #/Email:      

Social Worker’s Name (if applicable):       ______________________ Contact #/Email:      

Reason(s) for 15-day drop?1 Transportation issues 4 Teen parent/pregnancy2 Chemical or Mental Health concerns 5 Other/Unknown :      3 Unstable housing

Prior intervention(s)?1 Suggest alternative school 5 Meet with school-based mental health professional2 Suggest on-line course(s) 6 Suggest flexible day/shortened day3 Work with be@school 7 Other      4 Meet with chemical health professional

Current Credit Status:Earned Credits:      

Needed Credits:      

Current Educational Placement:

1 General Ed2 Special Ed

Current Grade:1 6th Grade 4 9th Grade 7 12th Grade2 7th Grade 5 10th Grade 8 GED or3 8th Grade 6 11th Grade Transitional

Yes No UnknownCurrent Individual Education Plan (IEP)? 1 2 8

Current English Language Learner (ELL)? 1 2 8

Has student been expelled from school in the past? 1 2 8

Student’s Current Living Situation (choose only one):1 Chemical Dependency Treatment:

Inpatient6 Relative/Extended Family Home 11 Inpatient Psychiatric

Facility/ Hospital2 Homeless with parent 7 Emergency Shelter Facility 12 Residential Treatment Center3 Parental Home (biological or adoptive) 8 Independent Living 13 Group Home4 Correctional Facility 9 Residential Correctional Program 14 On run5 Homeless without parent 10 Foster Home: Formal 15 Shelter Foster Home

Other information:       Notes:      

Contact: Alexia Poppy, School Social Worker Phone: 952-374-5786 Fax: 952-593-1272 Email: aapoppy@district287.org

Version 5 - Updated: Jun 2013 by Wilder Research

DIPLOMA ON!Referral Form

Contact: Alexia Poppy, School Social Worker Phone: 952-374-5786 Fax: 952-593-1272 Email: aapoppy@district287.org

Version 5 - Updated: Jun 2013 by Wilder Research