McCreary Academy Referral
1. School Making Referral / Referral Type ( check all that apply)
MCHS MCMS PKIS WCE / Academic Behavioral Emotional/Social
2. Student Identification Information
Name: / DOB: / Age: / Grade:
Guardian 1: / Relationship:
Address: / Work # / Home # / Cell # / Alternate #
Student lives with: Both parents One parent Blended Relatives Guardian Self Friends
3. Reason for referral:
Please check factors or characteristics that apply to this student:
Retained one or more years
Failed 2+ subjects (recent semester)
Sudden drop in grades
ESL
Exceptional Children’s status/category/disability______
Excessive Absences/Tardies
Frequently skips class
Frequently leaves school early
Suspensions
Displays aggression, bullying, anti-social behavior
Displays inappropriate, attention-getting behavior
Involved in delinquent activities
Experience with bullying as victim
Withdrawn/Change in behavior
Lacks social skills; difficulty with peer relationships
Suspected gang involvement
History of abuse/neglect/dependency or domestic violence
Suspected alcohol, substance use/abuse
Pregnant/parenting
Health concerns______
Mental health concerns
Developmental issues
Family income too low to provide basic necessities
Sibling has dropped out of school or is teen parent
Prior or current DCBS referral
Frequent moves
CDW or Court or DJJ involvement
Homeless
4. School Interventions attempted:
Social/Emotional
Parent conferences
Student conferences
Schedule change
School based counseling Person counseling:______
Peer Advisor/Mentor/Buddy
YSC Referral
Home Visits
Academic
RTI Reading Tier II or Tier III Name of intervention specialist:______
RTI Math Tier II or Tier III Name of intervention specialist:______
Online Classes: ______
Exceptional Children
Special Education screen
Currently receiving special services
Behavioral
RTI Behavior Tier II or Tier III
School Behavior contract
Assigned to in-school suspension
Assigned to Alternative to Suspension
5. Referrals made for Community Interventions:
School charges filed against student? Charges:______
DJJ probation or committed? Name of worker ______
DCBS referral
IMPACT Services
Outside counseling
Residential Treatment? Diagnosis:______Facility:______Dates:______
Student Information: Check all that apply
Medication? Type:______
Medical conditions? Type:______
Suspected substance abuse?
Mental Health issues? Diagnosis:______
6. Necessary documentation if admitted to program :
Copies of past testing: KCCT, Explore, Plan, ACT, etc...
Cumulative Record/file folder with all mandated registration items.
Current IEP (if applicable)
7. Signature of School Administrator / Parent Notification of Referral
Date: ______By:______