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Glade Run Lutheran Services

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St. Stephen’s Referral Form

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Education
St. Stephen’s Referral Form

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Location/Program of Interest
- St. Stephen's Academy K-12, Zelienople
- St. Stephen's Academy K-12, Utica
- Day Treatment, Zelienople
- Transitions, Zelienople
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*
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- withdrawn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

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

(724) 452-4453
contact@gladerun.org

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