Student CIS Application

Student CIS Application

Student Information

Parent / Guardian Information (if student is a minor)

Applicant Status & Eligibility

Student is 18 years of age or older:   Has an Individualized Education Program (IEP):   Has a 504 Plan:

Services Requested

Please indicate the CIS services requested (check all that apply):

Reason for Referral

Briefly describe the primary concerns, goals for CIS involvement, and any immediate safety concerns.

Educational & Behavioral History

Recent disciplinary actions (suspensions/expulsions): Yes No

Supporting documents included (check all that apply):

Medical & Emergency Contact Information

Consent to Services, Records Release, and Acknowledgments

By signing below I authorize Comprehensive Intervention Services (CIS) staff to provide the services indicated above and to access educational, behavioral, and health records necessary for assessment, planning, and coordination of services. I understand that such access may include, as applicable, attendance records, academic records, disciplinary records, health office notes, and IEP/504 plan information.

I understand that information disclosed to or by CIS is protected by privacy rules but may be re-disclosed in limited circumstances required by law, including mandatory reporting of child abuse, imminent risk of harm to self or others, and court-ordered disclosures. I acknowledge that I may revoke this authorization in writing at any time except to the extent that CIS has already acted in reliance on it.

Communications: I authorize CIS staff to contact me at the phone numbers and email addresses provided for scheduling, service coordination, and case updates. Standard text message and email rates may apply.

Administrative Policies

Participation: CIS services are voluntary and may be discontinued by the applicant or guardian at any time by written notice. CIS may suspend or discontinue services for safety concerns or noncompliance with program expectations.

Confidentiality and Recordkeeping: CIS maintains records in accordance with applicable law and district policy. Records related to CIS services will be retained and disposed of in line with those policies.

Additional Information / Parent / Student Statement

Use this space to provide any additional information that may assist CIS staff in planning services or special instructions regarding participation.

Certification

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that knowingly providing false information may result in denial of services. I authorize CIS staff to contact the persons and organizations listed for the purpose of verifying information and coordinating services.

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