The Lincoln Center
Referral Source Questionnaire
The Lincoln Center
Referral Source Questionnaire

Student: ____________________________

Date: ____________________________

Referral Contact: ______________________



1.List any student health concerns:
________________________________________________________________________________________________________

________________________________________________________________________________________________________

2.List any medications taken by the student:
________________________________________________________________________________________________________

________________________________________________________________________________________________________

3.Is the student currently receiving treatment from a physician, psychologist, psychiatrist or receiving nursing services?
________________________________________________________________________________________________________

________________________________________________________________________________________________________

4.Is the student under any physician ordered restriction? ________________________________________________________________________________________________________

________________________________________________________________________________________________________

5.Describe the students’ communication abilities:
________________________________________________________________________________________________________

________________________________________________________________________________________________________

6.Have the students’ parents or guardian been active in educational planning?
________________________________________________________________________________________________________

________________________________________________________________________________________________________

7.What are the student’s independent abilities?
________________________________________________________________________________________________________

________________________________________________________________________________________________________

8.In what way are they dependent?
________________________________________________________________________________________________________

________________________________________________________________________________________________________

9.How does the student get along with other people?
________________________________________________________________________________________________________

________________________________________________________________________________________________________

10.Describe any student behavior(s) that interfere with instruction, stigmatize
or isolates the student or endangers the student or other people:
________________________________________________________________________________________________________

________________________________________________________________________________________________________

11.Have the student or their parents expressed any concerns regarding current
or future educational issues?
________________________________________________________________________________________________________

________________________________________________________________________________________________________

12.Describe any special skills or interest that you have observed?
________________________________________________________________________________________________________

________________________________________________________________________________________________________

13.Are there any issues regarding this student with which you are particularly concerned?
________________________________________________________________________________________________________

________________________________________________________________________________________________________

Briefly describe specific concerns related to the needs of this student
________________________________________________________________________________________________________

________________________________________________________________________________________________________

_______________________________________________________________________________________________________

________________________________________________________________________________________________________

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