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Charterhouse School Referral

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
Month
Day
Year
Student's Name*
First Last
Desired Start Date*
Month
Day
Year
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)*
- Autism Spectrum Disorder
- Blindness
- Deafness
- Emotional Disability
- Hearing Impaired
- Intellectual Disability
- Multiple Disabilities
- Orthopedic Impairment
- Other Health Impairment
- Other Neurological Difference
- Other (Please Specify Below)
- Specific Learning Disability
- Speech/Language Impairment
- Traumatic Brain Injury
- Vision Impaired
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*
Month
Day
Year
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
MM slash DD slash YYYY
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.

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UMFS is an independent 501(c)(3) corporation in the Commonwealth of Virginia. UMFS is an Equal Opportunity Agency. No one is denied care, assistance or employment on the basis of race, religion, national origin, color, disability, gender, veteran/military status, sexual orientation, ancestry or marital status.

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Charterhouse School Referral

To determine student eligibility, please answer the following:

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

Referral Source Information

Legal Guardian and Caregiver Information

Student Information

Child/Youth's Behaviors

Educational Information

Strengths/Needs

Attachments

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