Elk Grove Unified School District
Student Support Centers
Referral Form
David Reese Student Support Center Valley Student Support Center Prairie Student Support Center
392-9081 394-1634 (fax) 681-7577 681-7578 (fax) 422-1091 422-1152 (fax)
Coordinator ~ TBA Coordinator ~Annette Stringer, MS, PPS Coordinator ~ Annette Stringer, MS, PPS
RTPT - Penny Clemons (Florin Region) RTPT – Patricia Garcia -Secondary RTPT – Nory Cordero, MS, PPS - Elementary
RTPT - Sue Donovan (Elk Grove & Sheldon Region) (Laguna, Franklin, Valley Region) (Laguna, Franklin, Valley Region)
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REQUIRED INFORMATION
Date: ______Student #: ______
Student Name: ______Birth Date: ______
Grade/Track: ______School Site: ______
Parent(s)/Guardian Name(s): ______Parent’s primary language: ______
Home Phone #: ______Work Phone#: ______
Referring Person: ______Title: ______phone #:______
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SST/PTC: Took place on ______Parent attended SST/PTC q Yes q No
date
qIEP q504: q Yes q No SST/PTC/IEP meeting is scheduled for ______
date
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Basic service needs: q Clothing q Shelter q Food q School Attendance q Other Basic Needs ______
q Homeless ~ Current Living Situation (if known): ______
Medical: q Glasses/Eye Exam q Immunizations q Dental Care q Medical care q Connection to medical insurance
Counseling: q Counseling for student q Counseling for family q Bereavement Counseling/Group q Other Counseling
Additional Information and Other staff involved in intervention effort: ______
______
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Have you discussed your concerns with the parent(s)/guardian? q Yes q No
Have you discussed your concerns with the student? q Yes q No
Have you told the parent/guardian about the referral to the Student Support Center? q Yes q No
Please describe your contact with the parent or the student and include any other important information:
______
______
Office Use Only:
Living situation verified by______. Date______.
q 100- Temporary Shelter q 110- Hotel/Motel q120- Temporarily Doubled up q130- Temporarily Unsheltered
Rev 5/15 Elk Grove Unified School District