RCPS Behavioral Intervention
Referral Form

                                        	

To Be Completed By Referral Source or School Counselor

1.	IDENTIFYING INFORMATION (Please complete boxes)
Referral date:  		Student’s RCPS ID#:  
Student name:  Gender:   Female         Male	Ethnicity: 
School: 	Grade:       	Birth date: 	Age:  
Student address:  	Zip:  Parent/Guardian name(s):  
Home phone:  	Cell phone: 	Work phone:       
Custodial Rights:    Mother         Father	       Both     	  Guardian        State Agency        Other      
Does the student have a current IEP?    Yes        No   
If yes, Case Manager name:       	Consultant name:       
Does the student have a Section 504 Plan?    Yes       No  
Does the student and/or parent/guardian require an interpreter?    Yes        No      Language:        

2.	REFERRAL INFORMATION
Who is making this referral? (Name)  
Referrer is a:    School Counselor 	  Administrator	   School Social Worker  
	  Psychologist 	    	  Other Parent       
Referral source’s phone #:  	Email:  
To which school counselor is this student assigned? 	Phone #:            	Email:      
Has this student been staffed with your school’s RTI/SST/AST?   Yes        No
Date case was staffed or will be staffed (if applicable):      
In addition to this referral, please check any previous actions that have taken place in regard to this student.
 Individual Counseling
 Group Counseling
 Family Counseling
 ISS
 OSS
 CHOICES
 Alpha Academy
 Fresh Start
 DJJ
 Probation	 Previous Hospitalization 
 Drug Abuse Intervention
 Attendance Plan
 Behavior Contract
 Gang Contract
 Current Medication
 Behavioral Screening
 Evaluation
 P&I Specialist Involvement
 Other Support Services	

3.	CONCERN (including self-report/peer reports) 
	Does this student exhibit any of the following warning signs for at-risk behaviors?
Early Warning Signs (low-to-medium-risk factors/behaviors)	
 Social withdrawal
 Poor social skills
 Excessive feelings of isolation and of being alone
 Excessive feelings of rejection
 Feelings of being picked on and persecuted
 Persistent sadness
 Impulsive behavior
 Violent and/or aggressive behavior
 Uncontrolled anger
 Chronic disruptive behavior
 Bullying
 Stealing
 Homeless	 Intolerance for differences/prejudicial attitudes
 Low school interest/poor academic performance
 Excessive absences/Truancy
 Affiliation with gangs
 Drug use and/or alcohol use
 Expression of violence in writing and drawings
 Access to, possession of, and use of weapons
 Recent loss, grief
 Serious medical illness/traumatic injury
 Legal Issues
 Family Issues
 Lying/Manipulative behavior
 Other      	

Imminent Warning Signs (high-risk factors/behaviors)	
 Serious physical fighting
 Detailed threats of lethal violence
 Possession and/or use of firearms, other weapons
 Severe destruction of property
 Child Abuse & Neglect (CAN)	 Setting fires
 Severe rage for seemingly minor reasons
 Sexually aggressive behavior
 Other self-injurious behaviors or threats of suicide
 Sexualized behaviors	

What prompted this referral? What are your concerns about risk? Any additional comments you would like to include?

ITEMS 4 THROUGH 8 TO BE COMPLETED BY STAFF MEMBER MAKING REFERRAL.

4. 	PARENT/GUARDIAN/CUSTODIAL CONTACT
A.	Has the family been notified that that a referral for behavioral interventions has been made?     Yes         No  
B.	Name of family member contacted: 
C. 	Has family member signed Consent for Behavioral Health Screening and/or services? 	  Yes         No  

5. 	OTHER PROFESSIONALS INVOLVED WITH STUDENT (for each yes, enter corresponding information below)
Child Welfare Services	  Yes        No  	Juvenile Court	  Yes        No  
Mental Health Provider	  Yes        No  	DJJ		  Yes        No
Physical Health Provider	  Yes        No 	Other      
Name	       Agency	                          Phone number
     	     	     
     	     	     

6. SERVICES RECOMMENDED/REFERED:
  Screening        	  P&I Services	  SBMH Services       	  CB MH/AD Services 	  Counselor
        	        	        	        	        
Date referred	Date referred	Date referred	Date referred	Date referred

If School-Based MH Services recommended, who will contact AFE with referral information?
Name:	Title:	Phone Number: 

7. My signature is acknowledgement that I have reviewed all of the information contained in this document.
    
    Referrer’s Signature:               Date: 
** Please Sign and return to P&I Specialist for Processing/Data Entry.**

8.   For Internal Use Only 
  Initial P&I referral	  Repeat P&I referral 	  Initial SBMH referral 	  Repeat SBMH referral 
  Initial Community-based referral	  Repeat Community-based referral 
Referral Processed By:       		Date:       	
P&I Specialist OR SBMH Therapist Assigned to Case: