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Glade Run Lutheran Services
Glade Run Lutheran Services
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  • About Us
    • Who We Are
    • Sanctuary
    • Volunteer
    • Careers
    • Locations and Contacts
  • Autism
    • Wraparound
    • Summer Camps
    • Support Classrooms
    • Transitions
    • Independent Living Experience (ILE) Program
    • Jeremiah Village
  • Mental Health
    • Outpatient Counseling
    • Blended Case Management
    • Intensive Behavioral Health Services
    • Family Based Services
    • School Based Mental Health
    • Psychiatric Rehabilitation
    • Psychiatric Mobile Medication
    • Acute Partial Hospitalization
  • Education
    • St. Stephen’s Academy
    • St. Stephen’s Referral Form
  • Adventures
    • Programs and Services
    • Camps
    • Sensory Playground
  • Foundation
    • Individual Giving
    • Church & Congregation Support
    • Events
    • In Kind Drives
    • Corporate Gifts
  • Donate Now!

St. Stephen’s Referral Form

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  3. St. Stephen’s Referral Form

Step 1 of 4

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  • Referral Source

  • MM slash DD slash YYYY
  • Student Information

  • Please enter a number from 5 to 99.
  • Contact Information for Legal Guardian

  • These Items Must Be Included Prior to Enrollment

    *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)

  • Interventions

  • Ability/Achievement

  • MM slash DD slash YYYY
  • Psychiatric

  • MM slash DD slash YYYY
  • Educational Services

  • Community Services

  • Educational Services

  • Psychiatric Hospitalization(s)

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Alternative School Placement(s)

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Legal Placement(s)

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Residential Placement(s)

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
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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
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