District Referral Form

District Referral Form
YesNo
Which Member District:
Therapeutic Day ProgramABA / Autism ProgramRecovery ProgramShort-Term Suspension or IAES Placement40-Day Extended Evaluation45-Day Evaluation
Student First Name*
Student Last Name*

LASID*
SASID*
Student's Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Student Date of Birth*

MonthDayYear
Date
Current School*
Grade*
MaleFemaleNon-Binary
Race*
Ethnicity*
Reg ED504 PlanSpecial ED
Primary Disability
IEP Start Date*

MonthDayYear
Date
IEP End Date*

MonthDayYear
Date
Referring District*
Fiscal District (If Different)
District Contact*

First NameLast Name
District Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
District Contact Email*
This email will receive an automatic response when this form is submitted.
District Contact Email - Additional Recipients - 1
This email has been requested for forwarding by WPS.
Legal Guardian First Name*
Legal Guardian Last Name*
Relation to Student*
Legal Guardian & Education SignerLegal Guardian Only
YesNo
Guardian's Current Address (If different from student)*

Street Address

Street Address Line 2

CityState

Zip Code
Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Guardian Contact Email*
example@example.com
YesNo
YesNo
YesNo
DCF Worker First Name
DCF Worker Last Name
DCF Phone
Please enter a valid phone number.Format: (000) 000-0000.
DCF Email
example@example.com
Educational Surrogate Parent First Name
Educational Surrogate Parent Last Name
Educational Surrogate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Educational Surrogate Email
example@example.com
Educational Signer First Name
Educational Signer Last Name
Educational Signer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Educational Signer Email
example@example.com
Student First/Native Language*
Students Language of Instruction*
YesNo
Access Score/EPL Level, if applicable
YesNo
Primary Language of Parent (if different from student)
YesNo
YesNo
For Woodward Day School Only
Incident Date

MonthDayYear
Date
Number of LTS Days
Reason for LSA
Suspension End Date

MonthDayYear
Date
Attendance Data
2024-2025 Attendance Data
2024-2025 Number of Absences*
2024-2025 Number of Tardies*
2024-2025 Number of Dismissals*
2023-2024 Attendance Data
2023-2024 Number of Absences*
2023-2024 Number of Tardies*
2023-2024 Number of Dismissals*
Summary of Attendance: (For attendance issues, please provide dates and explanation of significant events such as hospitalization)*

0/340
Academic Data
Strengths:*

0/225
Areas of Need:*

0/225
Current effective academic supports/accommodations:*

0/225
Additional supports recommended:

0/300
Discipline/Behavior Data
Summary of Discipline and/or Behavioral Concerns:*

0/340
Summary of current effective supports/interventions:*

0/340
Additional interventions recommended:

0/340

Referral Checklist
Required before interview/intake: The sending school is responsible for ensuring the following information/paperwork is submitted before setting up an interview/intake. Upon receipt of all required information, an interview/intake with the student will be scheduled.
- Signed Authorization to Release Information for CMC from the district
- IEPs
  - Current signed Individualized Education Program and most recent quarterly progress reports.
  - Proposed Individualized Education Program
- School Records
  - Transcripts and current/most recent academic grades (interim grades/report cards)
  - 504 Plan / BIP / Safety Plan
  - Attendance Records
  - Discipline records including Suspension Letters
  - Home Language Survey
  - Assessments for ELL Students (ACCESS)
  - “Opt-out” notice for ELL services (if applicable)
- Evaluations
  - Most recent Educational Evaluation/Assessment
  - Psychological Evaluation, OT/SLP/PT Evaluations, if applicable
  - Functional Behavioral Assessment/Behavior Intervention Plan, if applicable
  - Other student assessments, if applicable (e.g., risk assessments, safety assessments, CRA)
Upon District Acceptance of Placement at CMC, one of the following will be required:
- Signed IEP and Placement Page
- Signed Extended Evaluation Consent Form and N1
Required before the first day at CMC:
- Parent registration packet
- Immunization records (HIPAA Protected - Please fax to 508-854-1689)
Required for Woodward Day School Only:
- UPDATED N1 to reflect WDS as IAES
- Numerical grades at the time of exit from the district
Upload Referral Forms Here:*

Cancelof
All information above must be submitted at the time of referral unless otherwise stated. If any documents are missing, please note the reason.
YesNo
Please provide the reason:
Footer (Last Name, First Name)
See Uploaded Document Statement
Should be Empty:

District Referral Form

For Woodward Day School Only

Attendance Data

Academic Data

Discipline/Behavior Data

Referral Checklist