/ R.I.S.E. Program
1315 South Broadway
New Ulm, MN 56073
ph(507) 359-8760
fax (507) 359-1380
Doug Hazen, Coordinator

REFERRAL FORM
for CONSIDERATION of
R.I.S.E. (Reaching Independence through Structured Education) PROGRAM

The R.I.S.E Program is for ASD or DCD students. These students are separated into two separate classrooms to address their individual needs. This program serves students, K-12, who need individualized environments, academic and/or functional skill development, and behavioral support.

Date:______

Student’s Name:______
Grade:______Date of Birth:______
Referring District: ______

Contact Person ______Phone: ______
Is the student receiving ASD or DCD services at least 21-60% of their school day? ______
Has the River Bend Special Education Coordinator observed/consulted with the special education case manager concerning this child?______

Identify the concerns and problems that the student has been encountering:
______

List any medication currently and previously taken by the student. Include name of medication, amount prescribed, how often taken, etc.
______
Academic strengths of the student:
______
Academic weaknesses of the student.
______
Academic Achievement Levels (Ex: Reading: 5.2, etc.)
Reading:______Math:______Written Expression:______
Student’s Full-Scale IQ: ______

Social History

Family structure (parent, stepparent, siblings, adoption, etc): Issues or concerns to be aware of: ______

School history (including concerns or areas of difficulty): ______

______

Medical history (serious illness or current health issues): ______

______

Contact information from anyone involved with mental health history: ______

Legal issues (CHIPS, delinquency, out-of-home placement, drug issues, etc.)

______

/ River Bend R.I.S.E.Program
1315 South Broadway
New Ulm, MN 56073
ph(507) 359-8760
fax (507) 359-1380
Doug Hazen, Coordinator

Health Information

Student: ______DOB: ______

Address: ______Grade: ______

______Sex: ______

Home Phone: ______

Mother’s Name: ______Mother’s Work Number:

______

Mother’s Address: ______Mother’s Cell Phone:

______

Father’s Name: ______Father’s Work Phone: ______

Father’s Address:______Father’s Cell Phone: ______

______

Parent Authorized Designee to p/u student if parents are unavailable:

Names:Phone Numbers:

______

______

Present Health Status of Student

____ Good – No adaptations needed

____ Has a chronic illness or disability

Name of chronic illness or disability: ______

Medication or Treatment: ______

____ Has allergies

Treatment: ______

Physician’s Name: ______Phone # ______

Address: ______

Parent/Guardian Signature: ______Date: ______

/ River Bend R.I.S.E. Program
1315 South Broadway
New Ulm, MN 56073
ph(507) 359-8760
fax (507) 359-1380
Doug Hazen, Coordinator

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

Client Name: ______Date of Birth ______

I authorize River Bend to ___ Exchange with or ____Disclose To or _____Obtain From: ______

Name of Organization & Individual ______

Mailing Address ______

City/State/Zip: ______Telephone # ______Fax ______

The information is necessary for the following purpose:

_____ Evaluation/Treatment____ Other ______

Information to be released (circle Yes or No)

Yes No Evaluations, notes/summaries including Psychiatric, Psychological, Medical, Chemical Dependency

Yes No Service date

Yes NoCourt/Corrections Information

Yes NoSchool or Educational Information (may include academic progress,

behavior issues, special education data)

Yes NoSocial Services Agency Information

Yes NoOther (specify) ______

I UNDERSTAND THAT:

* This information may include chemical dependency information

* I have the right to revoke this authorization at any time by given written notice to River Bend Education District. I understand that the revocation will not apply: 1: to information that has already been released in response to this authorization or 2: to my insurance company as the law provides my insurer with the right to contest a claim under my policy.

* I need not sign this authorization to receive services unless the services are court-ordered or are being created solely for a third party (i.e., consultation)

* River Bend can not prevent the re-disclosure of records released as a result of this request and that after release from River Bend, the records may not be subject to privacy rule protections.

* This authorization will permit two-way telephone communication and exchange of information by electronic methods.

* I’m entitled to a copy of this authorization once I have signed it and I may review/request copies of information disclosed.

* A photograph or facsimile of this authorization is as effective as the original.

This authorization shall remain in effect until this date: ______(one year maximum)

______

Client Signature DateWitness SignatureDate

______

Parent/Guardian SignatureRelationship to Client Date

------

A copy of this authorization to obtain information was sent to the above agency on

(date) ______by ______

Signature Date Signed: Date Expires: Entered By