Charterhouse School Referral Form - UMFS | Virginia Foster Care | Residential Treatment

To determine student eligibility, please answer the following:

Does the child have an IEP?*

Yes
No

Is the student approved for private day placement?*

Yes
No

Thank you for your interest in Charterhouse School. Please contact the IEP committee chair at your local school to find out how to seek approval.
Richmond — 804.239.1080 x1294
Edinburg — 540.984.6266

Preliminary Information

Today's Date

Student's Name*

First Last

Desired Start Date*

Location*

Program*

Person Making this Referral*

First Last

E-mail*

Title*

Phone*

Extension

Program*

What special education services does the child receive? (Check all that apply)*

Specify Other

How did you hear about us?*

Where was the ad placed?

Referral Source Information

Locality

Associated with an agency?

Yes
No

Agency Name

Worker Name

First Last

Title

Worker Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Worker Phone

Extension

Fax

E-mail

Supervisor Name

First Last

Title

Supervisor Phone

Extension

Legal Guardian and Caregiver Information

Legal Guardian*

Other

Where is the child currently placed?*

Agency Name

Worker Name

First Last

Title

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Extension

Email

Resource Parent Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Extension

Email

Name of Group Home

Worker Name

First Last

Title

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Extension

Email

Legal Guardian's Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Day Time Phone*

Email

Student Information

Date of Birth*

Age

Gender*

Race/Ethnicity (Check all that apply)

American Indian/Alask. Nat.
Asian (Non-Pacific Isl.)
Black, African American
Hispanic, Latino
Pacific Islander
White (Non-Hispanic/Latino)
Multi-Ethnic/Racial
Other (Please Specify Below)

Other (Specify)

Referred to UMFS/CHS before?*

Yes
No

Date of Last Referral

Child/Youth's Behaviors

Is the student currently at risk for harming self or others?

Yes
No

Provide details of this behavior

Describe current behaviors at home, school, etc. (include frequency)

Describe interventions in the past that have been effective in addressing these behaviors

Describe any other significant behaviors in the child's past not noted above. Is there a current risk for these behaviors? Why or why not?

Is there a history of runaway behavior?

Yes
No

Please Explain

Educational Information

Current or most recent school placement

Other School Placement

Current or most recent school name

Contact Name

First Last

Title

Phone

Extension

Fax

Current or most recent Local Education Agency (LEA)*

Phone

Extension

Email

Current Grade Level

IQ (if known)

Vocational/Independent Living Needs (as applicable)

Disability

Strengths/Needs

What are the child/youth's strengths, interests, skills, and talents?

Additional Comments/Notes

Attachments

Please attach recent psychological, social history, medical or academic records, if applicable. Alternately, records may be e-mailed to intake@chs4u.org or faxed to 804.239.1060 for the Richmond campus or 540.242.4225 for the Edinburg campus.

Drop files here or

Max. file size: 10 MB, Max. files: 8.