CHESTER COUNTY INTERMEDIATE UNIT

STUDENT SUPPORT SERVICES / STUDENT SERVICES / CCAEP / STEPS

CLASS / PROGRAM REFERRAL FORM

Name of Student: ______

Date of Referral: ______PASecureID Number ______

School District: ______School: ______

Teacher: ______Grade: ______D.O.B. ______

Parent/Guardian: ______Parent Phone Number: ______

Address: ______

REFERRING DISTRICT INFORMATION

Individual Authorizing Referral: ______Title: ______

Contact Person (if different than authorized person):

Name ______Title: ______

Phone Number of Contact Person: ______E-Mail Address of Contact Person: ______

For IU use:

PROGRAM/CLASS REFERRAL

Discussion with Other Internal Referral Sources

(If Appropriate): _____ Yes _____ N/A

Who: ______Date:______

Who Designated to Contact District Person: ______

Status of Referral: ____ Accepted ____Not Accepted

If Accepted, Tentative Beginning Date: ______

Date of Response to District Contact Person: ______

If not within 10 days, cite reason why ______

Date of Verification by District that Transportation is Arranged: ______

Date Medical Records Requested: ______

PROGRAM/CLASS REFERRAL

PLEASE CHECK APPROPRIATE PROGRAMS

/

IU CONTACT

Child and Career Development Center
Specify Type of Class: / Sue Mateka
610-383-7400,
Chester County Alternative Education (CCAEP)
Specify whether Regular or Special Ed Student: / Lisa Tzanakis
484-237-6000,
STEPS
Specify whether Regular or Special Ed Student: / Lisa Tzanakis
484-237-6000,
Cross District Emotional Support Class / Jacalyn Auris
484-237-5039,
Cross District Life Skills Support Class / Jacalyn Auris
484-237-5039,
Cross District Multiple Disabilities Support Class / Jacalyn Auris
484-237-5039,
Cross District Autism Support Class / Jacalyn Auris
484-237-5039,
IU Partial Hospitalization or Mental Health Based Programs
Specify whether CARE, REACH, TEACH or RISE: / Sue Lombardi
484-237-6006 x6222,
Cross District Hearing Class / Vince McVeigh
484-237-5013,
Speech and Language Services / Lillian Neary
484-237-5045,
Home and Community Services (Wraparound/Personal Care Assistants) / Cathy Scanlon
484-237-5192,
WCU/CCIU Community Classroom / Diane Tallman
610-383-7400,
Transitional Living Program (TLP) - Oxford / Diane Tallman
610-383-7400
Transitional Living Program (TLP) – West Chester / Diane Tallman
610-383-7400
CHANGES D&A Partial Hospitalization & Outpatient Program / Sue Lombardi
484-237-6006 x6222,
CHOICES / Cris Chambers
484-237-5064,
CHAAMP / Jacalyn Auris
484-237-5039,
Psychological Services/Evaluation / Cris Chambers
484-237-5064,

Reason for Referral/Areas of Concern: ______

REQUIRED INFORMATION ATTACHED FOR PROGRAM / CLASS REFERRAL

IEP: _____ Yes (Date Implemented: ______) _____ No _____ N/A

504 Services Agreement Plan: _____ Yes (Date Implemented: ______) _____ No _____ N/A

NOREP: _____ Yes (Date Signed: ______) _____ No _____ N/A

Evaluation Report: _____ Yes (Date of Report: ______) _____ No _____ N/A

FOR REACH & TEACH: Has Dr. Newbrough conducted an evaluation of the student:___ Yes ___ No If yes, Please Attach

FOR SECONDARY STUDENTS: Transcripts Attached: ___ Yes ___ No; Attendance Record Attached: ___ Yes ___ No

FOR CCAEP/STEPS: Days of Suspension this year ______Any Eval Needed: _____ Yes, Specify: ______

_____ No

Length of Stay: _____ Regular (45 day minimum)

_____ Diagnostic (Up to 45 days)

_____ Expulsion (Length of Expulsion:______)

_____ Transitional (Alternative placement to Home District)

_____ Other: ______

Can student return mid-marking period if level achieved? _____ Yes _____ No