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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