LEE COUNTY SCHOOLS

McKinney-Vento (Homeless) Referral Form

Student Information: Students Needs Assessment:

Student’s Name:
D.O. B. / // / SS# / --
Grade: / SIMS#
School:
Parent/Guardian:
Phone# / ()-
Temporary Address
Referring Person:
Position
Living Conditions
Student is unaccompanied youth
Guardianship is a problem
Student lacks permanent residence
Student & family live doubled up with
Student (only) lives with relatives
Student lives with Mom only
Student lives with Dad only
Student lives in substandard housing
Student lives in a shelter
Student lives in motel
Enrollment Issues
Academic records needed
Student unable to pay school fines
Immunization records needed
Birth Certificate is needed
Free lunch form has not been returned
Physical
Transportation to school
Student needs clothing
Family needs food
Student needs after school care
Health Related
Health problems indicated
Immunizations are needed
Eye Exam needed
Physical Exam needed
Medications needed
Academic
Student is absent excessively
Student needs tutoring
Counseling
Family in Conflict/Crisis Situation
Evidence of Domestic Violence
Evidence of Physical Abuse/Neglect
Behavior indicates need for counseling
List Names/Ages of Other Children in the Home:
Age
Age
Age
Age
Comments:
Qualifies for Other Programs
Title I / LEP
EC / Migrant
Other

Services Provided:

Tutoring or other instructional support
Expedited evaluations
Staff development and awareness
School Supplies
Referral to other programs and services
List:
Emergency assistance related to school attendance
Referrals for medical, dental or other health services
Transportation
Early Childhood Programs
Assistance with participation in school programs (before/after school tutorials, mentoring, and summer school).
Assistance in obtaining/transferring records necessary for enrollment
Parent Education related rights and resources for children
Coordination between schools and agencies, Counseling
Addressing needs related to domestic violence
Clothing to meet school requirements
Other Service:
Additional Comments:

Social Worker’s Signature: ______Date: ______