TST BOCES Little Lighthouse and Possibilities Programs
(K-12th grade)
(K-5th grade)
2015-2016 Referral Form
(FAX COMPLETED FORM TO JAYDN MCCUNE 607-257-2510)
This referral is for:
_________Little Lighthouse
____________Possibilities ___________ Undecided
Name of student __________________________ Date of Referral ________________
Person completing this form ______________________
(Name)
________________________
(your role)
Your Phone #_____________________ Email __________________________________
Student’s School __________________________ Grade _____ Birthdate ___________
Parent/Guardians ___________________ Phone _______________________________
Parent/Guardians ___________________ Phone _______________________________
Address _________________________________________________________________
Does the student have an IEP? Yes No Does the student have a 504 Plan? Yes No
Please describe the reason for referral or the nature of the crisis situation:
How long have these concerns been present?
Please identify specific times when the concerns are not interfering with the student’s
success:
Please identify several of student’s strengths and interests: (i.e. extracurricular activities,
community involvement, character traits, etc.)
How would you know that a Little Lighthouse or Possibilities admission had been
successful for this student?
On a scale from 1-5 where 1 = the worst it has ever been and 5= the best it could be for
this student, please rate the following and circle the corresponding number
Worst
Best
Student’s behavior
1----2----3----4----5
Student’s academic functioning
1----2----3----4----5
Student’s social/emotional well-being
1----2----3----4----5
School’s relationship with the family
1----2----3----4----5
Attendance
1----2----3----4----5
Please identify the adults in the school that the student would identify as a support
person.
Name________________________________ Position___________________________
Name________________________________ Position___________________________
Please send along with this referral:
____IEP/504
_____ Psychological assessment if available
____Attendance Record
____ Discipline Record
____Report Card
____ Student’s Schedule
____Strengths and Difficulties Questionnaire (Part II of this referral form)
Please note! This referral will not be processed unless Parent/Guardian Form (PART
III) is also submitted. When complete, Fax this form to 257-2510 and make a copy of
this referral for the student’s school record.
Call Jaydn McCune 257-1555, ext. 5046 with questions.
Little Lighthouse/Possibilities Referral Part II (referral source to complete)
TST BOCES Little Lighthouse/Possibilities Program
Family Referral (Part III)
We invite you to please review the Little Lighthouse and/or Possibilities Family
Brochure to read more about the program(s) before filling out this form!
Please share the following information about your child:
Student’s Name __________________________________DOB __________________
Parent/Guardian Name(s) _________________________________________________
Phone _______________________________ Email ____________________________
1. My child’s strengths and interests are:
2. My child could benefit from your program because:
3. How would you know that a Lighthouse admission had been successful for this student?
4. My main contact at the school is: ____________________________________________
Community Supports:
Has your child ever had a psychiatric hospitalization? Y/N
If Yes, where? _________________ if currently hospitalized, tentative discharge date ____________
Does your child have a psychotherapist or counselor? Y / N
Provider Name:_______________________________________________________
Is your child been seen by a Psychiatrist? Y / N
Provider Name________________________________________________________
Is your child on Medication? Y / N
Who is prescribing the medication? ______________
Other agencies/programs that support my child are:
On a scale from 1-5 where 1 = the worst it has ever been and 5= the best it could be for
this student, please rate the following and circle the corresponding number
Worst
Best
Student’s behavior
1----2----3----4----5
Student’s academic functioning
1----2----3----4----5
Student’s social/emotional well-being
1----2----3----4----5
School’s relationship with the family
1----2----3----4----5
Student’s attendance
1----2----3----4----5
RELEASE OF INFORMATION:
I give permission for my child to be referred to the Little Lighthouse and/or
Possibilities Program and for the referring school to share pertinent information with
Program Staff. I understand that some of school records that can be sent to the
programs include:
IEP/504 Plan if applicable
Student’s transcript
Student’s discipline records
School attendance records
Student’s schedule
Psychological Assessment if available
___________________________________________________________________
Parent/Guardian Signature
Date
FAX COMPLETED FORM TO JAYDN MCCUNE 607-257-2510