Skip to content

Donate Now!Careers Volunteer News & Events Contact Us

Facebook Twitter YouTube Linkedin

GRL2018

Just another WordPress site

About Us
- Who We Are
- Sanctuary
- Volunteer
- Careers
- Contact Us
Autism
Mental Health
Education
- St. Stephen’s Academy
- St. Stephen’s Referral Form
Adventures
Foundation
Donate Now!

Search:

About Us
- Who We Are
- Sanctuary
- Volunteer
- Careers
- Contact 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

Education
St. Stephen’s Academy
St. Stephen’s Referral Form

Step 1 of 4

25%

Location You're Interest In
- St. Stephen's Academy, Zelienople
- St. Stephen's North, Sharon
Referral Source
Parent/Guardian School District*
Date Completed*
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- withdrawn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*
Psychiatric
Date
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

News & Events

Specialized Adventures Summer Camp
Specialized Adventures Camp A social skills development camp for individuals …
Extended School Year Program

Christmas Angel Program
Bring a smile to a child or family in need …
Independent Living Experience
Glade Run is proud to host a week-long independent living …

Contact Us

P.O. Box 70 Beaver Road,
Zelienople, PA 16063

(800) 371-0545
Info@gladerun.org

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

Dream-Theme — truly premium WordPress themes