Student Recommendation Form Last Name: First Name: Grade: as possible to assist in determining eligibility for CIS Please check (√) all areas of concern for this student and provide as much information services. If the student receives appropriate consent and is eligible for CIS services, CIS staff will develop a service plan and coordinate appropriate services for the student. The student may be served at school or referred to an outside agency for services. Attendance: Academics: Behavior: Social Service Needs: Program: ______________________________________________________________________________________________ My relationship to this student is: Staff Referral CIS Self Teacher Principal Counselor Enforcement Parent Principal Assistant School Law Nurse Court Youth Hotline _______________ Peer School Juvenile Texas Other: I would like to talk to a CIS staff person about this student. The best time to reach me is: convenient time: Morning Afternoon Evening Contact number: ( ) Comments: Signature: Date: (Signature must be in ink) Please return this form to the CIS office. Thank you. CIS Use Only Follow-up Note:________________________________________________________________________ _____________________________________________________________________________________ CIS Staff Signature: Date:
Student Recommendation Form Last Name: First Name: Grade: Please check (√) all areas of concern for this student and provide as much information as possible to assist in determining eligibility for CIS services. If the student receives appropriate consent and is eligible for CIS services, CIS staff will develop a service plan and coordinate appropriate services for the student. The student may be served at school or referred to an outside agency for services. Attendance: Academics: Behavior: Social Service Needs: Program: ______________________________________________________________________________________________ My relationship to this student is: CIS Staff Self Referral Teacher Parent Principal Assistant Principal School Counselor Law Enforcement Peer School Nurse Juvenile Court Texas Youth Hotline Other: _______________ I would like to talk to a CIS staff person about this student. The best time to reach me is: Morning Afternoon Evening convenient time: Contact number: ( ) Comments: Signature: Date: (Signature must be in ink) Please return this form to the CIS office. Thank you. CIS Use Only Follow-up Note:________________________________________________________________________ _____________________________________________________________________________________ CIS Staff Signature: Date: