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phoenix academy

APPLICATION

School Administrators & Teachers, 

Referrals to Phoenix Academy should come from  the learner's school district with shared commitment from parent(s)/guardian(s). Completion of this form initiates the referral process to Phoenix Academy. Please note that submission does not guarantee placement. Each application is reviewed by our admissions and clinical team, and the referring school or agency will receive a response within seven (7) school days.

Phoenix Academy is committed to partnering with districts to ensure the best possible match between each learner’s needs and the level of support our clinic-based model provides.

Services Requested:
Birthday
Month
Day
Year
Does the student have any of the following?
Are parents/guardians aware, supportive, and involved in the application process?
Yes
No
In the works
Check all of the following behaviors the student is currently exhibiting
How often does problem behavior occur?
Select the intensity level based on the most severe problem behaviors the learner demonstrates:
Level 1: Aggression resulting in (a) no marks on body and (b) no blows close to or contacting the eyes
Level 2: Aggression resulting in (a) reddening of skin and/or (b) mild swelling
Level 3: Aggression resulting in (a) light scratches (b) small or shallow breaks in skin and/or (c) moderate to severe swelling
Level 4: Aggression involving blows close to or contacting the eyes or resulting in attention from medical personnel
Where does the problem behavior most often take place
When does the problem behavior most often take place
Which professional roles have been involved in the student's current educational or clinical support?
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