01. Student Information

02. Parent/Guardian Information

03. Referral Information

04. Page

Supported by Education Success Foundation • The Sands Family Campus • 16 Lake View Park Rochester, NY 14613

Monroe County Lighthouse Referral Form

Thank you for taking the time to refer a student to the Monroe County Lighthouse at EnCompass. The information you provide below will help us provide the highest level of service to our students.

Student's Demographic Information

Student's Name

Student's Preferred Name

DOB

MM

/

DD

/

YYYY

Case Number

Primary Language

English

Spanish

Other:

Sex Assigned at Birth

Male

Female

Gender Identity

Female

Male

Other:

Race (check all that apply)

Asian

Native Hawaiian/Other Pacific Islander

Black/African American

American Indian/Alaska Native

White/Caucasian

Other:

Ethnicity

Hispanic/Latino

Not Hispanic/Latino

Student's Current Address

Student's School Information

Current School

Current School District

Please select

Student's School ID Number

Please upload student's most recent report card

Delete all uploads

Choose files or drag here

Please upload a copy of the student's most recent Casey Life Skills Assessment

Delete all uploads

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A requirement for a students to be enrolled in the Lighthouse is a minimal full scale IQ of 65. Does the student meet this requirement?

Yes

No

Check any support services the student receives:

IEP

504 Plan

Behavior Plan

ESL

Other:

Does the student receive any of the following support services?

Yes

No

IEP

504 Plan

AIS (Academic Support Services)

ESL (English as a Second Language)

Behavior Plan

Speech/Language Therapy

Physical Therapy

Occupational Therapy

Counseling

1:1 Aide

12:1:1 Classroom

15:1 Classroom

Bus Aide

If you answered "yes" to any of the support services, please upload documentation here:

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Choose files or drag here

Student's Health Information

Does the student have any food allergies?

Yes

No

Describe the student's food allergies:

Does the student have any non-food allergies?

Yes

No

Describe the student's non-food allergies:

Does the student take any medication?

Yes

No

List the medications the student takes:

Does the student have any medical conditions we should be aware of?

Yes

No

Describe any medical conditions:

Does the Student have a Mental Health Diagnosis?

Yes

No

Select the Mental Health Diagnoses the student has

Depression

ADHD

Anxiety

Bipolar

Schizophrenia

Conduct Disorder

ODD

OCD

PTSD

CPTSD

Autism

N/A

Please List other Diagnosis Not specified:

Did the student have any hospitalizations (i.e., Medical, Mental Health) over the last 30 days?

Yes

No

Describe why the student was hospitalized.

Does the student have sexualized behaviors?

Yes

No

Describe the student's sexualized behaviors.

Has the student engaged in any of the following behaviors?

Choose all that apply

Physical Aggression/Property Destruction

Smoking/Vaping

Car Theft

Self-Harm

Police Contact

Mental Health Arrest

AWOL

N/A

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01. Student Information

02. Parent/Guardian Information

03. Referral Information

04. Page

Supported by Education Success Foundation • The Sands Family Campus • 16 Lake View Park Rochester, NY 14613

Monroe County Lighthouse Referral Form

Guardian Information

Parent/Guardian 1

Relationship to student

Parent/Guardian 1

Foster Parent

Mother

Father

Other:

Phone

Parent/Guardian 1

Parent/Guardian Email

Parent/Guardian 1

Is there at 2nd parent/guardian to enter information for?

Yes

No

Parent/Guardian 2

Relationship to student

Parent/Guardian 2

Foster Parent

Mother

Father

Other:

Phone

Parent/Guardian 2

Parent/Guardian Email

Parent/Guardian 2

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01. Student Information

02. Parent/Guardian Information

03. Referral Information

04. Page

Supported by Education Success Foundation • The Sands Family Campus • 16 Lake View Park Rochester, NY 14613

Monroe County Lighthouse Referral Form

Referral Source Information

Your Name

Agency

Title

Email Address

Cell Phone Number

Your Relationship to Student

Referral Information

Are any of these factors concerns you have about the student?

No, this is not a concern

Not sure

Yes, this is a concern

Academic performance

Attendance at school

Behavior

Mental Health

Physical Health

Safety Issues

Substance Use

Why are you referring the student to the Monroe County Learning Hub at EnCompass?

Make sure to reference any of the factors you noted as being an area of concern above:

Has the student been suspended from school?

Yes

No

How long is the student suspended for?

Please describe why the student was suspended:

Describe the student's current living situation:

What (if any) support services does the student currently receive? Please describe which agencies the student is connected with and provide their point of contact information:

Is the student currently on probation or parole?

Yes

No

Describe the parole/probation arrangements, including PO Officer information:

Does this student have permission to use technology i.e. computer use, cell-phone, gaming systems, etc?

Yes

No

Restricted use

Please explain restrictions regarding technology use:

What else would be helpful for us to know about the student?

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01. Student Information

02. Parent/Guardian Information

03. Referral Information

04. Page

Supported by Education Success Foundation • The Sands Family Campus • 16 Lake View Park Rochester, NY 14613

Monroe County Lighthouse Referral Form

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