Skip to content

Donate Now!Careers Volunteer News & Events Contact Us Purchase Services

0

View Cart Checkout

No products in the cart.

Subtotal: $0.00

View Cart Checkout

Facebook page opens in new window Twitter page opens in new window YouTube page opens in new window Linkedin page opens in new window

Glade Run Lutheran Services

About Us
Autism
Mental Health
Education
- St. Stephen’s Academy
- St. Stephen’s Referral Form
Adventures
Foundation
Donate Now!

Search:

About Us
Autism
Mental Health
Education
- St. Stephen’s Academy
- St. Stephen’s Referral Form
Adventures
Foundation
Donate Now!

St. Stephen’s Referral Form

You are here:

Home
Education
St. Stephen’s Referral Form

pbis

Step 1 of 4

25%

Location You're Interest In
- St. Stephen's Academy, Zelienople
- St. Stephen's Utica
Referral Source
Parent/Guardian School District*
Date Completed*
MM slash DD slash YYYY
Contact Person*
Title First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Student Information
Student Name*
First Last
Gender*
PA Secure ID#*
Grade Level*
SSN#*
DOB*
Age*
Please enter a number from 5 to 99.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Contact Information for Legal Guardian
Relationship to Student*
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*

These Items Must Be Included Prior to Enrollment
Special Education Students
- IEP*
- ER*
- NOREP*
- Educational/psychological report
Does ER reflect current placement recommendations?
- Yes
- No
All Students
- Report cards*
- Immunization records (do not send originals) *
- State School Health Record (do not send originals)
*Please be aware that St. Stephen’s will require a credit count for high school students prior to the initial IEP meeting, so that we can do appropriate planning for the student.
Reason for Referral (check all that apply)
- defiance of school/classroom rules
- assaultive/physically aggressive behaviors toward:
- Peers
- Staff
- Family
- truancy
- negative peer interaction
- possession of weapon at school
specify weapon
- verbal aggression/threats/swearing toward:
- Peers
- Staff
- Family
- drug and/or alcohol involvement
note which substance if known
- property damage
- tobacco/smoking in school
- conflict with teachers/staff
- inability to meet classroom expectations
- failure to complete school work
- withdrawn
- lack of motivation
- inability to remain on task
- poor socialization skills
- unique learning style / inability to learn in traditional ways
- sensory differences that impact success in a typical school setting
- self injurious
- other
explain
Interventions
Is the student currently in school?*
State Reason:
If student is currently expelled, please state reason and length of duration:
Has the student been retained?*
If so what grade(s)?
Suspensions
Date/reason
Law enforcement*
Date/reason
Probation*
Name of probation officer

Ability/Achievement
Reading Level (grade equivalent)*
Math Level (grade equivalent)*
Full Scale IQ*
Date of most recent evaluation*
MM slash DD slash YYYY
Psychiatric
Date
MM slash DD slash YYYY
Axis I
Axis II
Examiner
Axis I
Axis II
Educational Services
- Speech Services
- Hearing Services
- Occupational Therapy
- Physical Therapy
- Vision Services
- OVR
- English Second Language
- Other
Community Services

Quick Links

About Us Autism Mental Health Education Adventures Foundation

Contact Us

P.O. Box 70, 30 Glade Run Drive
Zelienople, PA 16063

(724) 452-4453
contact@gladerun.org

Glade Run is a 501(c)(3)
non-profit corporation.

© Glade Run Lutheran Services | P.O. Box 70 Beaver Road, Zelienople, PA 16063 | Glade Run is a 501(c)(3) non-profit corporation. | Privacy Statement