Insight PA 2024-2025 SRS Referral Form

*Disclaimer* Student attendance and engagement will no longer be captured through this referral form as of SY 24/25. The form will be for referring SRS involvement with a student/family only. If you make a CYS/CYF/DHS/Childline Referral/Crisis Referral you MUST report that via this Google Form.

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Imminent Risk/Threat Assessment

Is an imminent safety risk to the student prompting this referral?

Situations posing a direct threat to the student (i.e. suicidal remarks/attempts, physical abuse, homicidal remarks, etc.)

Yes

Crisis Protocol

If you have not done so already, engage in the Insight PA Crisis Protocol before proceeding with the form.

I confirm I have followed the Crisis Protocol and have utilized the necessary supports.

Select or enter value

Stop Here

An SRS Referral is not appropriate until you have utilized the Crisis Protocol to handle immediate situations.

CYS Referral or SRS Referral Instructions

CYS Referral Only: Do not complete the rest of the SRS Referral form if this is a CYS Referral only. Complete this linked form CYS Referral Form

SRS Referral Only: No need to complete the CYS Referral, just complete the rest of the SRS Referral form only.

CYS and SRS Referral: Complete both the CYS Referral Form and the rest of this SRS Referral form.

Would you like to continue to submit an SRS Referral?

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Referral Source Contact Information

Your First Name:*

Your Last Name:*

Your Phone Number:*

Referral Source Email Address*

What is your position/role?*

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Student Information

Include the Student ID below:*

Please enter the student's "Student ID" number. Please click here to find the student's Student ID number.

Student's Last Name:*

Student First Name:*

Student's Current Grade:*

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Student's Gender:*

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Is the student receiving Special Ed?*

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SE Supervisor Associated

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Student County of Residence:*

IMPORTANT: Student Resource Specialists are assigned by counties, so this is a required item. Staff can refer to TotalView to verify county and select from the dropdown.

Select

Family ID of Referred Student:

Copy and paste Family ID from TotalView to ensure accuracy.

Referral Concern(s)

Primary Referral Concern:*

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Summary of Situation (prompting SRS referral)*

Please select the date the information regarding this referral came to your attention:

(It is important to choose the date you received the communication/knowledge, rather than the date you reviewed the message)

Supporting Information Type(s)

Select

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