School Pre-Pins Diversion Services Referral Form Page 2
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2Release of Information Consent
Has parent signed the Release of Information Consent Form? ____ Yes
____ No (If no, please explain)
__________________________________________________________________________________________
If the parent/guardian has not signed the Release of Information Consent Form, do not supply the information
below or include the accompanying documentation; instead, just sign this form at the end.
School Information
IEP? ____ Yes
____ No (If yes, please attach copy)
Special Ed? ____ Yes
____ No
(If yes, date of Manifestation Hearing: ____/____/____ ; and attach copy of letter of determination.)
Remarks: _________________________________________________________________________________
Was the case referred for services? ____ Yes ____ No If yes, what service?:__________________________,
what date referred?: ____/____/____, and what was the outcome?:____________________________________
__________________________________________________________________________________________
School Intervention Steps
Student Contacts:
Dates
Outcomes
1. Teacher
____/____/____
________________________________________________
2. Guidance Counselor
____/____/____
________________________________________________
3. Attendance Officer
____/____/____
________________________________________________
4. Other: _______________ ____/____/____
________________________________________________
Parent Contacts:
5. Phone
____/____/____
________________________________________________
6. In-School Conference
____/____/____
________________________________________________
7. Home Visit
____/____/____
________________________________________________
8. Other: _______________ ____/____/____
________________________________________________
9. Superintendent’s Hearing ____/____/____
________________________________________________
Social Service Agency Information (
available documents.
If child/family accessed services) Attach
Agency Name
Type of Service
Contact Person/Title
______________________ __________________________________ ___________________________
______________________ __________________________________ ___________________________
______________________ __________________________________ ___________________________
ALL INFORMATION AND DOCUMENTS MUST BE INCLUDED FOR THE ONEIDA COUNTY
PROBATION DEPARTMENT TO TAKE ACTION.
_____________________________________________________
____/____/____
Signature of Referrer
Date
_____________________________________________________
____/____/____
Signature of Building Principal
Date
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