School District of Philadelphia



SCHOOL DISTRICT OF PHILADELPHIA

MTSS/Rti/STUDENT ASSISTANCE PROGRAM

INITIAL REFERRAL FORM

STUDENT’S NAME:___ ADVISORY:__ _________

TODAY’S DATE:____ ___________________

REASON FOR REFERRAL:

_______ ____________________________________

PERSON REFERRING STUDENT:_.__

CONFIDENTIAL CONFIDENTIAL CONFIDENTIAL CONFIDENTIAL

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SCHOOL-BASED PROGRAMS

INFORMED CONSENT FOR BEHAVIORAL HEALTH ASSESSMENT

I hereby authorize the Student Assistance Program (SAP) assessor from Albert Einstein Healthcare Network to complete an assessment and referral process for

____ ___.

(Name of Student)

The SAP team at __Roosevelt Elementary School__ has recommended this assessment

School in order to determine if there are any barriers affecting your child’s learning.

This process will include:

➢ A clinical interview with the student to determine possible behavioral, mental health and/or substance abuse issues.

➢ An electronic at risk self-assessment (BH Works Survey, John Hopkins) for parents ages 5-11 and student self assessment for ages 12-21.

A parent/guardian and/or the student can verbally refuse to participate in completing this self-assessment tool.

Refusal does not affect participating in and completing the SAP assessment.

This process may also include:

➢ An interview/consultation with the parent or guardian

➢ A review of school records

➢ A consultation with appropriate school personnel

➢ Possible participation in an in-school support and/or skill-building peer group

Student’s Signature____________________________________ Date_____________

Signature of Parent/Guardian____________________________ Date_____________

Print Name __________________________________________

Relationship to student_________________________________

Witness______________________________________________ Date_____________

Please complete the following information to help the SAP assessor from Einstein access health care for your child. Thank you.

Name of Student __ _

Grade______________

Social Security Number ________________________ DOB___ _____

Street Address___

Phone Numbers: Home:_____ _____________

Work:__________________________

Cell:____________________________

Does this child have Health Insurance? (circle one) Yes or No

If yes, check the appropriate health insurance provider below.

Aetna/US Healthcare_____ Blue Cross _____

Health Partners _____ HMA _____

Keystone Mercy _____ Oaktree/Oxford_____

Other:___________________________________________

If you don’t have health insurance please contact your School nurse to help you find insurance.

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Einstein’s School-Based Behavioral Health Programs

Phone 215-456-9205

Fax 215-456-9367

SCHOOL-BASED PROGRAMS

RELEASE OF CONFIDENTIAL INFORMATION

I,(Parent/Guardian) ____ __, hereby authorize the School-Based Programs of Albert Einstein Healthcare Network to release to _Roosevelt Elementary School relevant information regarding the results of the clinical assessment of

________

(Name of Student)

The information (check off below), which may be released, is limited to:

✓ Dates of assessment & follow-up sessions

✓ Assessor’s recommendations

✓ Student response to recommendations

✓ Other:______________________________________________________

This information is required for the specific purpose of supporting educational progress and facilitating treatment where needed.

I understand that my authorization shall remain effective for a period of ninety (90) days from the date of my signature.

I also understand that I may revoke this authorization (except to the extent that action has been taken in reliance thereof) at any time by written, dated communication to School-Based Behavioral Health Programs, Albert Einstein Healthcare Network.

______________________________ _________________________ ____________

(Name of Parent/Guardian) (Signature/Parent/Guardian) (Date)

_______________________________ _________________________ ____________

(Name of Student) (Signature of Student) (Date)

_____________________________ ________________________ ___________

(Name of Witness)` (Signature of Witness) (Date)

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