Application and Referral Form | Community Country Day School

Name of individual completing this application *

First

Last

Please provide the name of the person completing this application. If you are a school district or a counseling office, please provide the name of the individual that you would like to serve as the primary contact for this application.

What is your relationship to the student? *

Parent / Guardian
School District representative
Counselor or other Referral Agency

Student Full Name *

First

Last

Student Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Cell Phone *

Email *

Student Birthdate

Age *

Social Security Number *

Current Grade *

Current School *

Father's Name *

First

Last

Father's Address

Address Line 1

Address Line 2

City

State

Zip Code

Mother's Name *

First

Last

Mother's Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Information

If your child has any of the insurances listed below please check the appropriate box(es):

If applicable, please list any private or other insurance the child is covered under

The purpose of obtaining this information is to determine the most appropriate services available to your child.

How well does the student get along with his/her teachers? *

Describe the student's attitude toward school. *

What, if any, physical handicaps does the student have? *

Does the student have any diagnoses? *

Yes
No

Does the student take medication? *

Yes
No

Does the student have behavioral concerns? *

Yes
No

Has the student ever been on probation? *

Yes
No

Student Needs

My child has ADHD, ADD, ODD, OCD, or RAD
My child has an IEP
My child has asthma or allergies
My child has received counseling/mental health services

If your child has received counseling / mental health services, please indicate from whom. If they have not received services, please indicate N/A: *

My child is receiving or has received services from one or more of the following agencies: *

Office of Children and Youth
Drug and Alcohol Counseling
Juvenile Justice
Erie County Office of Mental Health and Intellectual Disabilities
None of the above

Apply/Refer

Insurance Information