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CHESAPEAKE CENTER FOR STUDENT SUCCESS REFERRAL (Chesapeake Public Schools)

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_____________________________________________________________________________________
_______________________________________________________________________________________
CHESAPEAKE CENTER FOR STUDENT SUCCESS – REFERRAL
605 Providence Road
Chesapeake, VA 23325
Phone: (757) 578-7046
Fax: (757) 578-7068
Date: ___________________
Student’s Name: ___________________________________ Grade: ____________
Date of Birth: __________________ Age: _______________ Home phone: ______________________
Student’s Address: _____________________________________________________________________
School Making Referral & Referral Date: ____________________________________________________
Person Making Referral & Position: ________________________________________________________
Reason For Referral: ____________________________________________________________________
Mother/Guardian’s Name: _______________________________________________________________
Work Place & Phone: ___________________________________________________________________
Father/Guardian’s Name: ________________________________________________________________
Work Place & Phone: ___________________________________________________________________
Is this student a foster child? _______ Yes _______ No
Does this student have a social worker? ______ Yes ______ No
Name of Social Worker: __________________________________ Phone Number:__________________
Has this student been referred for truancy? ______ Yes ______ No
If yes, what is the present status? ________________________________________________________
Has student gone through ID? ______ Yes ______ No
Has the student been to court? ______ Yes ______ No
Has this student been through the ESTAT process? ______ Yes ______ No
What interventions were implemented? Brief Summary: _________________________________________
_________________________________________________________________________________________
CHESAPEAKE CENTER FOR STUDENT SUCCESS – REFERRAL CON’T.
Does this student have a probation officer? ______ Yes ______ No
Name of Probation Officer: ________________________________ Phone: ___________________________
Does this student receive lunch assistance? _______ Reduced _______ Free _______ No
Is this student presently going through the CSC process? _______ Yes _______ No
Does this student currently receive Special Education Services? _______ Yes _______ No
Does the Special Ed. Student have a Functional Assessment and Behavior Intervention Plan?
_______ Yes _______ No
When was it last reviewed? _______________________
Has this student received Special Education Services in the past? _______ Yes _______ No
If yes, please describe: ______________________________________________________________________
Please fax a copy of the following information with this referral to (757) 578-7068:
_______ Schedule
_______SAP Report (Report Hub)
_______IEP (If Applicable)
_______Student Discipline History (Report Hub)
_______ Immunization Record
_______ Pertinent Medical Information
Principal’s Signature: ______________________________________________ Date: _____________________
Parent/Guardian’s Signature: ________________________________________ Date: _____________________
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CHESAPEAKE CENTER FOR STUDENT SUCCESS REFERRAL (Chesapeake Public Schools)

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Completed 19 April 2021

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