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KIND Kids In New Directions REFERRAL FORM Page.1 of 2 Directions: Person making the referral will complete this form, inform the parents and obtain the parent's signature. Send the referral form to KIND via e-mail, fax (810) 664-1011 or mail to: 1996 W. Oregon, Lapeer, MI 48446. Contact the director at (810) 245-3978 with any questions.
*Please note, it may be necessary to obtain internal authorization before submitting this form to the KIND office.
Child's Name D.OB./Age Sex
Address City Zip
Father's Name Address Phone
Mother's Name Address Phone
Legal Guardian(s)
Step-parent (living with child)
School Grades Teacher(s) Previous K.I.N.D. referral? ___Yes ___No _________Date (approximate) Please check the appropriate column concerning this child. |
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BEHAVIOR Referring Party ___ uncooperative ___ generally cooperative ___ inconsistent behavior ___ withdrawn ___ class clown ___ Sleeps in class ___ Obscene language ___ argumentative ___ lying ___ stealing ___ restless ___ nervous, jittery ___ ___________ ___ ___________ |
Parent ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ |
ACADEMIC Referring Party ___ doesn't do homework ___ easily frustrated ___ cheating ___ dissatisfied in school ___ high achiever ___ satisfactory or above ___ decline in grades ___ no effort ___ irresponsible ___ short attention span ___ academic failure ___ low motivation/interest ___ ___________ ___ ___________ |
Parent ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
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ATTENDANCE Referring Party ___ new to school ___ attends regularly ___ frequent absences ___ frequent tardies ___ frequent requests to leave room ___ leaves assigned locations ___ ran away from home ___ _______________ ___ _______________
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Parent ____ ____ ____ ____ ____ ____ ____ ____ ____
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APPEARANCE/HEALTH Referring Party ___ appears healthy ___ often ill ___ lacks coordination ___ frequently complains of illness ___ low stamina ___ unusual smell ___ neglects personal appearance ___ _______________ ___ _______________
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Parent _____ _____ _____ _____ _____ _____ _____ _____ _____
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SOCIAL BEHAVIOR & RELATIONSHIPS Referring Party ___ negative change in friends ___ sudden popularity ___ avoids peers ___ seldom expresses feelings ___ peer exclusion ___ defensive with adults ___ bully with peers ___ talks about family concerns ___ family previously involved with protective services ___ speaks angrily of family ___ talks about feeling picked on ___ recent loss in family ___ talks about drugs/alcohol ___ mentions sibling problems ___ depressed feeling talked about ___ talks of suicide or murder ___ peers have reported concerns ___ _________________ ___ _________________
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Parent ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
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EXTRA CURRICULAR Referring Party ___ participates in sports ___ cuts practice ___ loss of eligibility ___ quit team/squad ___ participates in church activities ___ decreased participation ___ ___________ ___ ___________
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Parent _____ _____ _____ _____ _____ _____ _____ _____ |
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PRIMARY REASON FOR KIND REFERRAL: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ SPECIAL EDUCATION (CIRCLE): Yes No L.D.: __Yes __No E.I.: __Yes __No ADD: __Yes __No ADHD: __Yes__ No Last I.E.P.C._________ |
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SCHOOL INTERVENTIONS ATTEMPTED/IMPLEMENTED (check): |
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___ parent/teacher meetings ___ detentions ___ behavior charts ___ seclusion (in class) |
___ suspension ___ referrals to other agencies ___ tutoring ___ other, please describe: ___________________ |
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Signature of Referring Party: Date: Phone:
Signature of Parent: (or referring parties initials if phone approval) Date: Phone:
The referring individual will be requested to schedule and initial meeting between all parties (KIND, family school personnel) within ten days of the KIND Director's acceptance.
*Parent signature indicated interest in participating in KIND program. ------------------------------------------------------------------------------------------------------------ Date referral received: ____________ Accepted ______ Assigned to:_________ Date:__________ Funding Source(s) _______________________Reason for denial:_______________ Referral Agency: ___________________________
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