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Refer A Student to BrainSTEPS CO

Fill out the following form to refer a student to the BrainSTEPS CO program. All referrals to BrainSTEPS CO should only be made after receiving parent approval. Fields with a light-yellow background are required. The information you enter will be submitted to the appropriate BrainSTEPS CO team in the student's geographic area. Once your student referral has been electronically sent to the BrainSTEPS team, please allow several days for the team leader to contact the parent and school.

	Student:	First Name MI Last Name DOB (e.g. 01/01/2009) Current Age Sex Assigned at Birth Male Female Current Identification Select gender... Male Female Transgender Non-binary Not Listed Here Race Other Select race... American Indian or Alaska Native Asian Black or African American Hispanic/Latino White Native Hawaiian or Other Pacific Islander Two or More Races Select Language... English Spanish Vietnamese Chinese, Mandarin Russian Amharic Somali Nepali French Korean Burmese Hmong Karen, Pa'o Swahili Tigrigna Hindi Chinese, Yue Telugu Tagalog German, Standard Other (please specify):
	Referral Contact Information:	Name Email Phone Cell
	Primary Parent Contact Information:	Name Email Phone Cell Address Address (2)     City State Zip Select state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Out Of US Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Parent's Primary Language Other   Select Language... English Spanish Vietnamese Chinese, Mandarin Russian Amharic Somali Nepali French Korean Burmese Hmong Karen, Pa'o Swahili Tigrigna Hindi Chinese, Yue Telugu Tagalog German, Standard Other (please specify):
	School Contact (if you have this information):	Contact person name Title     Phone Email Academic year Select academic year... 2009 - 2010 2010 - 2011 2011 - 2012 2012 - 2013 2013 - 2014 2014 - 2015 2015 - 2016 2016 - 2017 2017 - 2018 2018 - 2019 2019 - 2020 2020 - 2021 2021 - 2022 2022 - 2023 2023 - 2024
	Injury Information:	Age at injury Educational placement prior to injury Regular Education Special Education Section 504 Select classification... Intellectual Disability Hearing Impairment including Deafness Speech or Language Impairment Visual Impairment including Blindness Emotional Disturbance Orthopedic Impairment Other Health Impairment Specific Learning Disability Deaf-Blindness Multiple Disabilities Autism Traumatic Brain Injury Developmental Delay Gifted Support Under Review Not Exceptional Screened, not recommended for evaluation Date of injury (ex. 01/01/2009) Classroom grade prior to injury Select grade... Not School Age Pre-Kindergarten Kindergarten (1/2 Day) Kindergarten (Full Day) 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Post     Has this student received BrainSTEPS / Brain Injury Resource Team consultation in the past for a previous injury? No Yes Date of referral: District: Select district... Adams 12, Northglenn-Thornton Adams 27J, School District 27J Adams 29J, Bennett Adams 31J, Strasburg Adams-Arapahoe 28J, Aurora Arapahoe 1, Englewood Arapahoe 2, Sheridan Arapahoe 26J, Deer Trail Arapahoe 32J, Byers Arapahoe 5, Cherry Creek Arapahoe 6, Littleton Archuleta 50 JT (Pagosa Springs) Aspen 1 Bayfield 10JT-R (Bayfield) Bent Re-1, Las Animas Boulder RE1J, St. Vrain Valley Boulder RE2, Boulder Valley Cheyenne R-1, Kit Carson Cheyenne RE-5 Denver 1, Denver Dolores Re-2J (Dove Creek) Dolores Re-4A (Dolores) Douglas Re 1, Castle Rock Eagle Re 50, Eagle (Formerly part of Admin Unit 64093) El Paso 12, Cheyenne Mountain El Paso 14, Manitou Springs El Paso 2, Harrison El Paso 20, Academy El Paso 22, Ellicott El Paso 23 Jt, Peyton El Paso 28, Hanover El Paso 49, Falcon El Paso 54 Jt, Edison El Paso 60 Jt, Miami-Yoder El Paso 8, Fountain El Paso RJ1, Calhan Elbert 100J, Big Sandy (Simla) Elbert 200, Elbert Elbert 300, Agate Elbert C-2, Kiowa Fremont Re-2, Florence Garfield 16, Grand Valley Garfield Re-1, Roaring Fork Garfield Re-2, Rifle Idalia RJ-3, Idalia Jefferson R-1, Lakewood Kit Carson C-20 Arriba/Flagler Kit Carson R-23, Hi-Plains Kit Carson R-4, Stratton Kit Carson R-5, Bethune Kit Carson RE-6J, Burlington Larimer R-1, Poudre Larimer R-2J, Thompson Liberty J-4, Liberty Lincoln C113, Genoa-Hugo Lincoln Re 23, Karval Lincoln Re 4J, Limon Mancos Re-6 (Mancos) Mesa 49Jt, DeBeque Mesa 50, Plateau Valley (Collbran) Mesa 51, Grand Junction Moffat Re 1, Craig Montezuma/Cortez 11 Jt (Ignacio) Montezuma/Cortez RE-1 (Cortez) Montrose Re-1J, Montrose Morgan Re-2 (J), Brush Morgan Re-20 (J), Weldon Valley Morgan Re-3, Fort Morgan Morgan Re-50 (J), Wiggins Otero 31, Cheraw Otero 33, Swink Otero R 1, East Otero (La Junta) Otero R 2, Rocky Ford Prowers RE-13Jt, Wiley Pueblo 70, Rural Silverton 1 (Silverton) SJBOCES-eSchool Teller Re-1, Cripple Creek Teller RE-2, Woodland Park Test District One Test District Two Washington R-104, Woodlin Washington R-2, Arickaree Weld 6, Greeley Weld Re-1, Gilcrest Weld Re-10, Briggsdale Weld Re-11, Prairie Weld Re-12, Pawnee (Grover) Weld Re-2, Eaton Weld Re-4, Windsor Weld Re-7, Platte Valley (Kersey) Weld Re-9, Ault-Highland
		Has child had a history of any of the following that have been MEDICALLY DIAGNOSED PRIOR to their brain injury occurring? History Unknown History of prior concussions? If so how many? 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 History of other type of brain injury that occurred at some point after birth? What kind? History of migraines? Family History of migraines? History of learning disabilities? If so, what type of learning disability? History of depression? History of anxiety? History of panic disorder or panic attacks? History of suicidal ideation? History of attempted suicide? History of other mental health and or emotional disorders? If so, what type of emotional disorders? History of sleep disorders or sleep issues? If so, describe. History of seizures? If so, describe. History of attention disorders (ADHD, ADD)? History of vision issues? If so, what type of vision issues? History of having a Lazy Eye History of dyslexia? History of motion sickness?
		Therapy Reading Therapy Currently in this therapy? School based Non-School based Current Speech Therapy Currently in this therapy? School based Non-School based Current Vision Therapy Currently in this therapy? School based Non-School based Current Physical Therapy Currently in this therapy? School based Non-School based Current Occupational Therapy Currently in this therapy? School based Non-School based Current Vestibular Therapy Currently in this therapy? School based Non-School based Current Hearing Currently in this therapy? School based Non-School based Current Mental Health Counseling Currently in this therapy? School based Non-School based Current Other Therapy Currently in this therapy? School based Non-School based Current Other therapy explain:
		Medications prior to brain injury If so, describe.
		What has this child experienced SINCE his/her brain injury: (does NOT need to be diagnosed) Migraines Depression Anxiety Panic disorder or panic attacks Suicidal ideation Attempted suicide Emotional outburst Social withdrawal from friends Fatigue Sleep issues (trouble falling asleep, trouble waking up, tired all day...) Seizures Spacy/Foggy Attention issues Vision issues? If so, what type of vision issues? Dyslexia Motion sickness
		Therapy Reading Therapy Currently in this therapy? School based Non-School based Current Speech Therapy Currently in this therapy? School based Non-School based Current Vision Therapy Currently in this therapy? School based Non-School based Current Physical Therapy Currently in this therapy? School based Non-School based Current Occupational Therapy Currently in this therapy? School based Non-School based Current Vestibular Therapy Currently in this therapy? School based Non-School based Current Hearing Currently in this therapy? School based Non-School based Current Mental Health Counseling Currently in this therapy? School based Non-School based Current Other Therapy Currently in this therapy? School based Non-School based Current Other therapy explain:
		Current Medications If so, describe.
	School District:	Select district... Adams 12, Northglenn-Thornton Adams 27J, School District 27J Adams 29J, Bennett Adams 31J, Strasburg Adams-Arapahoe 28J, Aurora Arapahoe 1, Englewood Arapahoe 2, Sheridan Arapahoe 26J, Deer Trail Arapahoe 32J, Byers Arapahoe 5, Cherry Creek Arapahoe 6, Littleton Archuleta 50 JT (Pagosa Springs) Aspen 1 Bayfield 10JT-R (Bayfield) Bent Re-1, Las Animas Boulder RE1J, St. Vrain Valley Boulder RE2, Boulder Valley Cheyenne R-1, Kit Carson Cheyenne RE-5 Denver 1, Denver Dolores Re-2J (Dove Creek) Dolores Re-4A (Dolores) Douglas Re 1, Castle Rock Eagle Re 50, Eagle (Formerly part of Admin Unit 64093) El Paso 12, Cheyenne Mountain El Paso 14, Manitou Springs El Paso 2, Harrison El Paso 20, Academy El Paso 22, Ellicott El Paso 23 Jt, Peyton El Paso 28, Hanover El Paso 49, Falcon El Paso 54 Jt, Edison El Paso 60 Jt, Miami-Yoder El Paso 8, Fountain El Paso RJ1, Calhan Elbert 100J, Big Sandy (Simla) Elbert 200, Elbert Elbert 300, Agate Elbert C-2, Kiowa Fremont Re-2, Florence Garfield 16, Grand Valley Garfield Re-1, Roaring Fork Garfield Re-2, Rifle Idalia RJ-3, Idalia Jefferson R-1, Lakewood Kit Carson C-20 Arriba/Flagler Kit Carson R-23, Hi-Plains Kit Carson R-4, Stratton Kit Carson R-5, Bethune Kit Carson RE-6J, Burlington Larimer R-1, Poudre Larimer R-2J, Thompson Liberty J-4, Liberty Lincoln C113, Genoa-Hugo Lincoln Re 23, Karval Lincoln Re 4J, Limon Mancos Re-6 (Mancos) Mesa 49Jt, DeBeque Mesa 50, Plateau Valley (Collbran) Mesa 51, Grand Junction Moffat Re 1, Craig Montezuma/Cortez 11 Jt (Ignacio) Montezuma/Cortez RE-1 (Cortez) Montrose Re-1J, Montrose Morgan Re-2 (J), Brush Morgan Re-20 (J), Weldon Valley Morgan Re-3, Fort Morgan Morgan Re-50 (J), Wiggins Otero 31, Cheraw Otero 33, Swink Otero R 1, East Otero (La Junta) Otero R 2, Rocky Ford Prowers RE-13Jt, Wiley Pueblo 70, Rural Silverton 1 (Silverton) SJBOCES-eSchool Teller Re-1, Cripple Creek Teller RE-2, Woodland Park Test District One Test District Two Washington R-104, Woodlin Washington R-2, Arickaree Weld 6, Greeley Weld Re-1, Gilcrest Weld Re-10, Briggsdale Weld Re-11, Prairie Weld Re-12, Pawnee (Grover) Weld Re-2, Eaton Weld Re-4, Windsor Weld Re-7, Platte Valley (Kersey) Weld Re-9, Ault-Highland
	Private school:
	County:	Select county... Adams County Alamosa County Arapahoe County Archuleta County Baca County Bent County Boulder County Broomfield County Chaffee County Cheyenne County Clear Creek County Conejos County Costilla County Crowley County Custer County Delta County Denver County Dolores County Douglas County Eagle County El Paso County Elbert County Fremont County Garfield County Gilpin County Grand County Gunnison County Hinsdale County Huerfano County Jackson County Jefferson County Kiowa County Kit Carson County La Plata County Lake County Larimer County Las Animas County Lincoln County Logan County Mesa County Mineral County Moffat County Montezuma County Montrose County Morgan County Otero County Ouray County Park County Phillips County Pitkin County Prowers County Pueblo County Rio Blanco County Rio Grande County Routt County Saguache County San Juan County San Miguel County Sedgwick County Summit County Teller County Washington County Weld County Yuma County
	BrainSTEPS:	Date of referral to BrainSTEPS Team (ex. 01/01/2009) Initial contact to BrainSTEPS initiated by School School - Concussion Management Team BOCES / Administrative Unit Family Advocate Rehabilitation Service Provider Acute Care Hospital / Physician Other
	Medical diagnosis as stated in medical record: Medical diagnosis as stated in medical record: Medical diagnosis as stated in medical record: Medical diagnosis as stated in medical record:	Traumatic Brain Injury     (moderate/severe) Non-Traumatic     Brain Injury Concussion(s)     (mild traumatic brain injury) Congenital Brain Injury No Formal Diagnosis      Select diagnosis... Motor Vehicle Accident (includes bicycles) Pedestrian Accident Falls Assault / Abuse Firearm Sports / Recreational Activities Abusive Head Trauma (previously called Shaken Baby Syndrome) Other (please specify): Select diagnosis... Anoxia Near Drowning Lightning Strike Stroke Aneurysm Tumor Seizure Disorder Hydrocephalus Encephalus Meningitis Toxic or Metabolic Injury Virus Other (please specify): Select diagnosis... Sports Assault / Abuse Fall Motor Vehicle Accident (includes bicycles) Other (please specify): Select diagnosis... Prenatal alcohol exposure Prenatal substance exposure In-utero Stroke Hydrocephalus Microcephaly Neural tube deficits Genetic disorders Other (please specify) Other
	Date of diagnosis:
	Notes:
	Verify Submission:

BrainSTEPS CO is a joint project between the Colorado Department of Education, the Colorado Brain Injury Program, and the Colorado Department of Human Services. The ORBS CO web application was developed by Leader Services, a division of LDP Inc. © 2016. Please send site-related issues to the webmaster.