Student Information


   

Thank you for your committment to youth facing serious/complex needs in our community.

Please fill out the following fields in order to submit a Referral Form to the Community Resource Coordination Group (CRCG) in your West Central Texas county. This form needs to be submitted at least 7 days prior to the requested CRCG staffing date. Exceptions will be made for emergency CRCG staffing. See the blue "CRCG Contacts" link above for staffing dates.

Fields with a red asterisk * are required in order to submit the Referral Form.

  
    • Student Information
      Enter the student’s legal name (and nickname if applicable) and Birthdate.
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      •  *
      •  *
      • MM/DD/YYYY
        Calendar
    • Living Situation
      Enter the student's (or parent's) phone numbers and answer the following questions about the student's living situation.
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      •  *
        xxx-xxx-xxxx
      • xxx-xxx-xxxx


    • Home Address
      Enter the student's home address. If the student is homeless, state "homeless" in the address field. Zip Code will auto-fill City, State, and County.
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      •  *
      • Address Not Verified
    • Demographic Information
      Select the student's demographic information.
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    • School Information
      Select the School District the Student attends (listed in alphabetical order), type in the School the student attends. Select the Grade Level of the student. County will auto-fill when you type in the Zip Code in the Home Address Section.
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      •  *
      •  *
    • Reason for Referral and Desired Outcome
      Briefly describe the reason you are referring this student to the CRCG and what outcome you are seeking from their involvement.
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    • Agency Involvement (past and present)
      List the Agencies that have been involved with this student in the past and those that are currently involved with assisting this student.
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    • List any agency representatives (and their phone numbers) that need to be in attendance for this meeting.
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    • Briefly describe the student’s background in the following fields.
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    • [+/-]
    • Student Status within the CRCG Referral Process
      Select one of the following: 1. Pending Parental Release - if the parent has not yet signed the release form 2. New - the parent has signed the release form and the referral is ready to be submitted to the CRCG *all other statuses are reserved for the CRCG Lead*
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      •  *
    • Contact Information for Person Making CRCG Referral
      Enter your name, the Agency or School you are with (if you are a Parent, please enter your name in the Agency field), and contact information. Select the date that you are requesting the CRCG meet (must be submitted 7 days prior to the requested CRCG staffing date).
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      •  *
      •  *
      •  *
      •  *
      • Calendar
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    • FINAL STEPS
      Please select "Submit the Referral Form" below to submit this Referral Form to the CRCG.
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    • MAKE SURE YOU KEEP YOUR CONFIRMATION CODE ON THE NEXT PAGE IN ORDER TO CHECK THE STATUS OF THIS SUBMITTAL.
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      •