Patient Progress Form

The Patient Progress Form is designed for school personnel to alert medical or mental health personnel that one of their 3-18 year old patients/clients has been identified as “at-risk” in an educational setting.  In addition, it will provide information about the targeted intervention to be provided, set the expectation that more information will be forthcoming, and include contact information for future communication.  Once a child has two positive gates on school-based screeners, this form will be faxed, along with the exchange of information form, to the provider.  Adaptations of this form will be developed for 0-3 providers.