Student Support Services Department
Child Welfareand Attendance Referral & Transition Form
Refer toReference Guide to Child Welfare and Attendance Referral Process regarding purpose/use of this form
Reason for referral (Check one only): Counseling Conference SARB Safety Transfer
Three DigitSchool ID Number School Name Date
Was a referral for this student submitted at any other time during this school year? Yes No
Reason for earlier referral: Counseling Conference SARB Expulsion Safety Transfer
Student's NameH0 NumberDate of BirthGradeGenderEthnicity
Foster Youth Homeless/Families &
AddressZipTelephoneYouth In Transition (FYIT)
Check here if parent/guardian needs interpretation
Parent/Guardian
Type of School: Elementary K-8
SchoolMiddle HighPrimary Language Spoken @ Home
Provide name and phone # for the following (if applicable):
Probation Officer/phone #Social/Case worker Agency/CBO/phone #Holder of Educational Rights/phone #
Mental Health Provider /phone #Health Care Provider/phone #
For Safety Transfer, please specify Police Case #
Special Ed. Student – Specify Program: / Section 504 StudentPlease attach a current (less than 11 months old) Individual Education Program (IEP) / For Section 504 students, please attach the current Service/Accommodation Plan
Referrals submitted without a current IEP or Service/Accommodation Plan will be denied and returned to the referring school.
Is student currently enrolled in a bilingual/ESL program? Yes No
Was parent/guardian notified of this referral? Yes No
(date)(school designee)
*High School Only: Current Credits: Expected High School Completion Date:
Reason for referral and brief summary of student history related to this concern:
Please describe this student’s strengths and area’s for growth:
Strengths / Areas of GrowthThe Student Support Services Department wants to provide effective support to the school site, so please indicate the types of interventions implemented on behalf of this student:
Teacher/parent conference / Referral to afterschool programs / TutoringBehavior contract / Peer Meditation/Counseling / CBO referrals, name:
Student participation in SAP / Referral to small group counseling
Student participation in SST / Referral to individual counseling / Case manager, name:
Student participation in SART / Mentor Program
Home Visit / Academic Counseling/Vocational/Career Preparation
Nursing Services / Referral to Wellness Program/Safe Passages Intervention
Youth Leadership/Development
Describe the outcomes of the interventions listed above:
Instructions:
To ensure that referrals are processed in a timely manner, please review final referral packet for completion and check that each of the following documents are attached. Incomplete documentation may delay the processing of the referral.
Submit for ALL referrals
SIS Counseling Notes / IF Spec Education or 504 (check dates/signatures)Attendance records for the academic year / Current Psycho-educational evaluation
Current report card/recent progress report / Current 504 Plan - if applicable
Scholarship record/Transcript / Current Individualized Education Program (IEP)
Test Scores / Current Behavior Support Plan -if applicable
Evidence of student participation in SAP and/or SST / Current Functional Behavioral Assessment - if applicable
If Applicable
Emergency Plan / Home Visit Report
Medication Form / Foster Care Placement Agreement
Must submit for Safety Transfer
Police report including report number. / Witness/Victim Statements (from every person listed on the Incident Report)Incident Report
Injury Report (only for serious physical injury) / Suspension Notices
Must submit for SARB
3 Notification of Truancy letters / Attendance Contract from: SART, Attendance-focus SST or Parent ConferencePlease submit two copiesfor a Counseling Conference or Safety Transfer referral and three copies for a SARB referral.
I have read the above referral and authorize its submission
School Principal SignatureDate
Name of person preparing referralTitleDate
EmailPhone
555 Portola Drive,San Francisco,CA94131 Tel: 415.695-5543 Fax: 415.695.5565
INTERVENTIONS/ACTIVITIES
DESCRIPTIONS
Academic Counseling: Personalized educational support, promoting, and enhancing the academic, personal, social, and career development of students. This may include written or verbal communications concerning the students' academic status and creating an individual academic plan to help students figure out what may be impeding their academic progress, and assist them in taking steps to address the problem(s).
After School Program: School and/or community based programs where students can access expanded learning opportunities during out-of-school hours.
Behavioral Support: School-based services that address student’s specific behavioral concerns including, but not limited to, Behavioral Intervention Plans, classroom observations, designated shadow, and/or school-site mental health professional support.
Educational Assessment: A special education assessment, functional analysis assessment, or other California Department of Education approved assessment.
Group Services: Group counseling/services at a school site or community based organization (e.g., transitions group, life skills, alcohol/drug, social skills, leadership, etc.).
Individual Counseling: Individual counseling with school-based, community or county based service provider.
Mentoring: One-to-one school or community based mentoring program (i.e. Big Brother/Big Sister, Court Appointed Special Advocates (CASA), Realizing our Youth as Leaders (ROYAL), SFUSD Student Mentor Program, Mentoring for Success Program, etc.).
Nursing Support: Ongoing monitoring of health issues and coordination of care between school, home and community.
Parent Involvement: Engage parent/caregiver support to improve student’s educational outcomes and progress.
Post-secondary Support/Planning: Support for planning or accessing post-secondary education and services (e.g., Guardian Scholars Program, Gear-up, AVID, Project Achieve, Upward Bound, AACE, etc.).
Student Assistance Program (SAP): The SAP is a learning support umbrella structure that brings together all support service providers at a school site. The SAP provides early identification, assessment, referral, support, and service coordination for students experiencing academic, attendance, behavior/social, or health problems that impact school success.
Student Attendance Review Team (SART): School-based multidisciplinary team, which meets regularly to review student attendance and create intervention plans for students with high rates of truancy.
Student Intervention Team (SB1895): Mental health services available to any special education student who is determined to need mental health assistance in order to access his/her education.
Student Success Team (SST): The SST is a problem solving and coordinating structure that assists students, families and teachers to develop positive solutions for maximizing student potential. It provides an opportunity for school staff, family members, community agencies and other important people to present their concerns about an individual student, and through discussion and study, to plan a positive course of action, assign responsibilities and monitor results for a student/family.
Summer Program: A school or community-based academic or enrichment program, which takes place during summer months.
Tutoring: Student is performing below grade level or is identified as needing school or community based individual or group tutoring services (e.g., FYS Tutoring Services, Supplemental Educational Services (SES), FYIT Tutoring Services, etc.).
Vocational/Career Preparation: Job training programs, job shadowing, internships, work experience (e.g., MYEEP, Jobs for Youth, Arriba Juntos, ROP, Jewish Vocational Services, Hire Up, Workability, etc.).
Youth Leadership/Development: Programs which provide youth leadership or youth development opportunities and/or programs (e.g., Athletic Team, Student Clubs, Youth Commission, California Youth Commission, youth advisory board, etc.).
(CWA Referral & Transition Form September 2009)Page 1 of 7