Dr. Mayer’s MemoJan. 2015

REQUIRED INFORMATION FOR A STUDENT’S RETURN TO THIS SCHOOL AFTER A HOSPITALIZATION OR OTHER ABSENCE AT A PROGRAM, FACILITY

OR TREATMENT CENTER.Note: An executed Release of Information Form is on file at our school.

1- Please provide this school a copy of both your initial intake form and your discharge summary. (Note: To adopt this form for use as is, leave generous spaces between numbered items.)

2- If this student received academic assistance at your program/facility, please detail your current academic status of this student. Please attach transcripts, but also detail here the specific subjects, proficiency level, and areas covered while in your program. Please inform this school of any deficits you have seen in this student.

3- Please detail what services your facility will continue to provide to this student. List days and times of continuing contacts.

4- If your facility’s assistance to this student has ended, what follow-up is or should be taking place elsewhere? Did you set-up this follow-up with the student? Please provide the time and place of the first appointment.

5- What are your specific and detailed recommendations for this school to assist this student moving forward? (Please have the person who delivered service to the student fill this section out.)

6- If this student is on medications, please list those here and outline any side effects or other concerns this school should be aware of throughout the student’s school day.

7- When will your assistance to this student end? If it has already terminated, please provide that date.

Initial Report___________ Update___________Signed_______________________________________Date____________

Printed Name_________________________________

Agency/Hospital/Program________________________________________

For an in-depth look at angry/violent teens read An Anger at Birth by J.E. Mayer. More at: www.jemayerbooks.com and www.DrJohnMayer.com