4. Student Information
6. Last Name:*
7. First Name:*
8. Middle Initial:
10. Race:*

    1. African American
    2. American Indian/Alaskan
    3. Asian
    4. Latino
    5. White
    6. Other
    7. Unknown
11. Sex:*

    1. Male
    2. Female
12. Date of Birth:*
    Date of Birth:
13. Child's Phone number*
    Numbers only.
15. Child's Address*
17. Address2
19. City
20. State
21. Zip
25. Referral Recommendation Originating Source
27. First Name:*
28. Last Name:*
29. Today's Date:*
    Today's Date:
31. Contact Information of Referral Source:*
    Phone number (XXX-XXX-XXXX).
32. E-mail:*
33. Role of Referral Source to Youth:*

    1. CASA
    2. Crossover
    3. Education Specialist
    4. Foster Parent
    5. LCCS
    6. Principal (not a single point of contact)
    7. Single Point of Contact
    8. Teacher (not a single point of contact)
    9. Probation Officer
    10. Other
34. Other:*
38. Education
40. Education Grade*

    1. preschool
    2. kindergarten
    3. 1st
    4. 2nd
    5. 3rd
    6. 4th
    7. 5th
    8. 6th
    9. 7th
    10. 8th
    11. 9th
    12. 10th
    13. 11th
    14. 12th
41. Name of School*
    -- Select One --Crossgates PreschoolDeVilbiss PreschoolArlington Elementary SchoolBeverly Elementary SchoolBirmingham Elementary SchoolBurroughs Elementary SchoolByrnedale Elementary SchoolChase STEM AcademyDeVeaux Elementary SchoolEast Broadway Elementary SchoolEdgewater Elementary SchoolElla P. Stewart Academy for GirlsElmhurst Elementary SchoolGarfield Elementary SchoolGlendale-Feilbach Elementary SchoolGlenwood Elementary SchoolGrove Patterson AcademyHarvard Elementary SchoolHawkins Elementary SchoolKeyser Elementary SchoolLarchmont Elementary SchoolLeverette Elementary SchoolLongfellow Elementary SchoolMarshall Elementary SchoolMartin Luther King, Jr. Academy for BoysMcKinley Elementary SchoolMcTigue Elementary SchoolNavarre Elementary SchoolOakdale Elementary SchoolOld Orchard Elementary SchoolOld West End AcademyOttawa River Elementary SchoolPickett AcademyRaymer Elementary SchoolReynolds Elementary SchoolRiverside Elementary SchoolRobinson Elementary SchoolRobinson Achievement CenterWestfield Achievement AcademyRosa Parks Elementary SchoolSherman Elementary SchoolSpring Elementary SchoolWalbridge Elementary SchoolWhittier Elementary SchoolBowsher High SchoolJones Leadership AcademyRogers High SchoolScott High SchoolStart High SchoolToledo Early College High SchoolToledo Technology AcademyWaite High SchoolWoodward High SchoolOther

    Name of school youth attends.
42. Special Education:*

    1. Yes
    2. No

    Is the youth in special education?
43. IEP:*

    1. Yes
    2. No

    Does the youth have an Individual Education Plan?
47. Reason for referral:*
51. Recommendation Information
    For internal use only.
58. Follow-Up
    For internal use only.
99. Youth: Change of Address
    For internal use only.
Leave This Blank:


109. 1. Receive an email copy of this form.
110. Email address

     This field is not part of the form submission.

111. Submit

* indicates a required field