RCSS COST Referral

This referral will be reviewed by the RCSS team to determine if one of the following district-level tier 3 supports is appropriate: - Mental Health Services - Behavior Support - ACC/FY/HY Support Please fill out this referral once all site-based tiered interventions have been exhausted or for immediate crisis situations.

Date of referral

School Year

Student First Name

Student Last Name

10 digit State Student ID #

(not district ID number)

School Site

Grade

Is student age 12 or older?

Primary Language Spoken at Home

Is student/family aware you are making this referral?

*Student (and/or parent if student is under age 12) need to be involved in the decision to make a referral for mental health counseling.

Reason for Referral

Please select all that apply

Select an option

Reason for referral

For any options selected above, please provide a brief description of the reason for referral.

{name}

Interventions Already Implemented

Please provide a summary of what has been done to far to address the concerns. *Please include site-based Tier 2/3 intervention data. Please indicate if crisis situation.

{name}

Does the student currently have, or has the student been referred to:

Select an option

Is this a referral for immediate crisis reasons?

(Suicidal/Homicidal Ideation, Severe psychosis/delusions, etc.)

Referring Person

Referring Person Email Address

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