FORMS

Have someone to recommend to us? Case Managers / Social Workers, please fill out this form.

If you prefer to fill out this form later, please print and fax our referral form to us at: 866.446.8303





County:

State:
 
Name of Student:

Age of Student:
Date of Birth:
SSN:
Gender:

Race:
School:
Grade:
Teacher(s):
Special Education or Resource:

In State Custody:
Parent/Guardian #1:
Relationship:
Parent/Guardian #2:
Relationship:
Parent/Guardian #3:
Relationship:
 
Home Street Address:
City:
State:
Zip:
County of Placement:
 
Alternate Address:
City:
State:
Zip:
 
Home Phone:
Cell Phone:
Work Phone:
Alternate Phone:
 
Academic Problem Synopsis:

 
Brief Social History:
 
Any safety issues in the home that would preclude in-home tutoring?
Service Begin Date:
Service End Date:

 

We recommend a 90 day period with reauthorization asssessment scheduled at the end of that period for possible continuation.

Frequency:

 

We recommend at least 4 hours per week for maximum effectiveness.

 
 

Rate: $25/hour per individual

$15/hour for 5-10 children in group instruction at a group home, community center,lock down facility, school, or library.

 
Total Amount Auth:
 
Case Manager Name:
Case Manager Electronic Signature:
 
Business Street Address:
City:
State:
Zip:
Phone:
Email:
Fax:
Cell:
 
Supervisor’s Name:
Supervisor’s Electronic Signature:
 
Phone: