Form JB-4
School Social Worker
2016-2017
Referral Form
One Team, One Goal: Student Success
Office Use Only
Date: Received: ______________
Referral Date:
First Contact: ________________
Student Name:
Date of Birth:
School:
Teacher:
Grade:
Demographic Information (complete below or attach Profile Page from On Track/CSIS)
Parent(s) Name:
Address:
Street
Apt.
City
Zip
Email Address:
Phone:
Home
Cell
Work
Attempts made by school to alleviate problem before referring to SSW (Required)
Date
Call
Letter
Conference
Outcome
Teacher
Administrator
REASON FOR REFERRAL: (attach correspondence)
CASE CATEGORY: (check all that apply)
Academic
Out of District
Attendance/Dropout**
Discipline
Group
Abuse (home alone)
Special Education
Family (includes: Economic Aid, Health, Glasses, Social/Emotional, Personal, Substance abuse)
**For attendance referrals, PPO must indicate in CSIS Notes: “(Date) student was referred to SSW for attendance concerns”
Referring Person’s Signature
Admin Signature
Please mark all dates of absences below (Mark according to Legend) Attach Printout
LEGEND
-Student Holiday
T – Tardy
X – Unexcused Absence
(X) – Excused Absence
E – Entry RE - Re-entry
WD – Withdrawal
-Student Holiday/staff day
7
14
21
28
6
13
20
27
NOVEMBER
1
2
3
8
9
10
15
16
17
22
23
24
29
30
MARCH
1
2
7
8
9
14
15
16
21
22
23
28
29
30
1
8
15
22
29
4
11
18
25
3
10
17
24
31
7/1/16: School Social Work
5
12
19
26
3
10
17
24
AUGUST
2
3
4
9
10
11
16
17
18
23
24
25
30
31
DECEMBER
1
6
7
8
13
14
15
20
21
22
27
28
29
APRIL
4
5
6
11
12
13
18
19
20
25
26
27
5
12
19
26
5
12
19
26
2
9
16
23
30
2
9
16
23
30
7
14
21
28
1
8
15
22
29
*JB-4*
SEPTEMBER
1
6
7
8
13
14
15
20
21
22
27
28
29
JANUARY
3
4
5
10
11
12
17
18
19
24
25
26
31
MAY
2
3
4
9
10
11
16
17
18
23
25
24
30
31
2
9
16
23
30
6
13
20
27
5
12
19
26
(REQUIRED)
3
10
17
24
OCTOBER
4
5
6
11
12
13
18
19
20
25
26
27
6
13
20
27
FEBRUARY
1
2
7
8
9
14
15
16
21
22
23
28
7
14
21
28
3
10
17
24
Number of Days Student
was absent last year:
*Unsigned or incomplete
forms will be returned
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