Grade: / DOB:
District Contact: / Email:
Date Parental Permission was obtained: / Parent/Guardian Name:
Parent Address:
Parent Phone Number:
Student has IEP: ☐Yes ☐No / Student has 504: ☐Yes ☐No
Student has Behavior Plan: ☐Yes ☐No / Referred to ACES Social Worker: ☐Yes ☐No
Additional Factors (Check all that apply)
☐Juvenile Office
☐Albany Regional Center
☐Family Guidance
☐Safe Schools Violations
☐Criminal Offenses
☐Division of Youth Services
☐Private Counselor
☐Weapons Violations
☐Drug/Alcohol Violations
☐Attendance Issues
☐DSM-5 Diagnosis
☐Medications
☐Previously Retained
☐Failing Grades
☐Discipline Issues
☐ Other (please explain): / Reason for Referral (Check all that apply)
☐Physically over reactive or aggressive
☐Verbally over reactive or aggressive
☐Impulsive or inattentive
☐Defiant or oppositional
☐Lack of motivation
☐Hyperactive
☐Pervasively sad or worried
☐Sexually acting out
☐Nervous or anxious
☐Unresponsive to support
☐Depressed
☐Social Skills
☐Lack of friends
☐Self-mutilation
☐Physical signs of stress or trauma
☐Other (please explain):
List the student’s hobbies and interests:
Describe things you would not want to change about the student:
Explain how long you have worked with the school team regarding the student concerns:
Describe the frequency, intensity, and severity of the behaviors:
Explain the general events, times of day, and situations that predict the occurrence of the behavior:
Describe previous interventions that have been tried, and note whether those were successful or unsuccessful:
Describe previous consequences and reinforcers that have been tried, and note whether those were successful or unsuccessful:
Describe any precipitating event for this referral:
In your opinion, describe the primary concerns regarding the student:
Describe staff limitations that have been identified, areas of expertise or support needed from ACES staff:
Anything else you would like the ACES team to know:
Please email your completed form to: Tamara Lynn, ACES Director