New Student Referral Form 2026-2027

New Student Referral Form

This application for admission is not to be constructed as a binding instrument on the part of the student or the school

Which type of referrer are you?

Rivermont School Campusrequired

Method referral received:required

Reason for Referralrequired

Referral source:required

Has this student been placed with Rivermont Schools before?

Yes
No

Student Information

Gender

Enrolling Graderequired

Student current residing school districtrequired

Responsible District

If different than residing district

Student primary exceptionality:

If yes, please indicate AIC placement:required

What is the desired classroom placement for the student?

When is the desired immediacy of placement for the student?

Current or recent past agency involvement including name of contact:

Please Identify target behaviors that require a more restrictive educational placement:

Behavior #1

Characters Remaining:

Behavior #2

Characters Remaining:

Parent/Guardian Information

Primary Parent/Guardian 1

Phone 1 Type

Parent/Guardian 2

Relationship to Student

Phone 1 Type

Any additional information regarding P/G? (relevant custody information? Etc.)

Characters Remaining:

Referral Process Status

Student documents received for review?

Yes
No

Enrollment Disposition

Select the final result of the student referral and the date the result was determined.

Referral Statusrequired

Reason for Student Waitlistrequired

Will the student need a 1:1 aide support?

Notes or Comments

Characters Remaining:

Documents

In order to complete the application process, the following items must be completed and attached in order for Rivermont School to consider acceptance. Rivermont School must obtain each item listed below before any student can be accepted and enrolled.

1. Current IEP* required to submit referral
2. Most recent Eligibility minutes
3. Psychological/Sociocultural Data
4. Educational Evaluations
5. Related Services Evaluations
6. Most recent report card
7. Most recent transcript
8. Current class schedule
9. Current Immunization Record
10. Comprehensive Physical Examination (within three years)
11. SOL/VAAP/VGLA testing data
12. Functional Behavioral Assessment
13. Behavior Intervention Plan
14. Residential/Hospitalization Documentation (discharge summaries, etc.)
15. Psychiatric Evaluation, including Axis I diagnosis

Please upload these documents below. If you can't upload all of the documents here please turn them in directly to the school.

Upload Referral Packet

When you are finished, please click 'Submit' to complete this form.