Medical referral form pdf 2026

1. Click ‘Get Form’ to open the medical referral form in the editor.
2. Begin by entering the student's name and the date at the top of the form. This information is crucial for tracking and processing referrals.
3. In the 'Referred by' section, select the appropriate role from the options provided, such as Counselor or Teacher. This helps identify who initiated the referral.
4. Next, indicate the reason for referral by checking one or more boxes under 'Reason for Referral'. Options include Academic, Attendance, Behavior, Emotional, and Substances. Providing detailed comments can enhance understanding.
5. Document any attempted interventions and their results in the designated section. This includes conferences with students or parents and other actions taken prior to this referral.
6. Finally, outline a follow-up intervention plan and assign staff responsible for implementation. Include a date for accountability.

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