Kaleidoscope Kollege

Referral Intake
Form

Educational resources and support planning for parents, students, military service veterans, and military-connected families with children who need additional academic, behavioral, or SEL support.

Completion Guidance

Use this form to request educational resources, parent guidance, student support planning, or referral coordination through Kaleidoscope Kollege.

This form helps identify student needs, family priorities, current supports, military-connected considerations, and requested next steps.

Important Notice

For emergencies, crisis situations, suspected abuse or neglect, or immediate safety concerns, contact emergency services or the appropriate mandated reporting authority. This intake is not for crisis response.

What Happens Next

Your referral is reviewed by the Kaleidoscope Kollege intake team within one business day.

A team member will follow up using your preferred contact method.

We will identify the right resources, support plan, or next steps for the student and family.

Kaleidoscope Kollege

Referral Intake Form

Complete all applicable sections. Fields marked required must be filled before submitting. All other fields are optional but help us provide the most relevant support.

0Intake Header

Referral source(optional)

Preferred follow-up method(optional)

Preferred language(optional)

Brief reason for referral

1Parent, Guardian, or Caregiver Information

Parent / guardian name

Relationship to student(optional)

Phone number(optional)

Email address

Street address(optional)

City, state, ZIP(optional)

Best days / times to contact(optional)

Preferred communication method(optional)

Submitter role(optional)

Parent / guardianCaregiverFoster parent or kinship caregiverCase managerSchool representativeCommunity partnerOther

Additional caregiver or household information(optional)Include anything that may help with support planning.

2Military Service Veteran and Military-Connected Family Information

Complete this section when the parent, guardian, caregiver, or student is a military service veteran, active duty service member, reservist, National Guard member, or part of a military-connected household.

Select all that apply(optional)

Parent / guardian is a military service veteranParent / guardian is active dutyParent / guardian is Reserve or National GuardStudent is a military-connected child or dependentFamily recently relocated or transitioned schoolsFamily is navigating deployment, reintegration, or separationFamily would like help locating education or family support resourcesFamily prefers not to share military-connected details at this time

Branch of service(optional)

Service status(optional)

Installation / base affiliation(optional)

Transition or relocation date(optional)

Military-connected needs, stressors, strengths, or context(optional)Include anything that may affect school support planning.

3Student Information

Student full name

Date of birth(optional)

Current grade level(optional)

Current school or program(optional)

Primary language(optional)

Student lives with(optional)

School district or campus contact(optional)

Student ID(optional)

Current educational plan or program(optional)

General education504 planIEP or special education servicesMTSS or RTI supportBehavior intervention planGifted or advanced academicsHomeschool or micro-schoolNot sure

Student strengths, interests, motivators, talents, or preferred activities(optional)

4Primary Area of Support Requested

Select all that apply(optional)

Academic skill supportReading or literacyMath supportWriting supportExecutive functioningOrganization and routinesBehavior supportAttendance or school engagementSocial-emotional learningSelf-regulation and coping skillsPeer relationshipsParent guidanceSchool meeting preparationResource navigationReferral coordinationOther

Top three concerns or goals for support(optional)

5Academic Support Details

Select all that apply(optional)

Difficulty with readingDifficulty with mathDifficulty with writingHomework completion concernsLow grades or missing assignmentsFocus or attention concernsTest anxiety or performance concernsLearning gaps after transition or absenceNeeds enrichment or advanced challengeNeeds study skills or planning supportNeeds tutoring referralNeeds school communication support

Most recent grades or progress notes(optional)

Current academic goals, if known(optional)

Describe academic concerns, patterns, or recent changes(optional)

6Behavior, Regulation, and Executive Functioning Details

Select all that apply(optional)

Difficulty following directionsDifficulty with transitionsTask refusal or avoidanceImpulsivityFrequent frustration or shutdownsAggression or unsafe behaviorElopement or leaving assigned areasSensory sensitivitiesDifficulty with routinesDifficulty managing materialsNeeds replacement behavior strategiesNeeds home-school consistency

Safety and support plan status(optional)

No known safety concernsParent has safety concernsSchool has reported safety concernsStudent has a behavior support planImmediate crisis support may be needed outside this intake

Describe behavior patterns, triggers, supports that help, and current strategies(optional)

7Social-Emotional Learning and Student Well-Being

Select all that apply(optional)

Needs help naming feelingsNeeds coping toolsNeeds confidence-buildingNeeds peer relationship supportDifficulty with emotional expressionDifficulty with conflict resolutionLow motivationSchool avoidanceGrief, family transition, or major life changeMilitary-related transition stressNeeds leadership or identity-building supportNeeds calm-down or reset tools

Describe SEL concerns, student voice, family observations, or school observations(optional)

8Current Supports, Services, and Documentation

Documentation available(optional)

IEP available504 plan availableBehavior plan availableRecent report card availableProgress monitoring data availableEvaluation or assessment availableOutside provider notes availableAttendance records availableParent wants help requesting school recordsDocumentation not available yet

Current school supports, community supports, providers, tutors, or programs involved(optional)

Documents attached or requested(optional)

9Requested Kaleidoscope Kollege Support

Select all that apply(optional)

Parent consultationStudent learning support planAcademic resource packetBehavior support strategy guideSEL resource packetSchool meeting preparationHome routine or expectations planReferral to community resourceMilitary-connected family resource guidanceVeteran parent / caregiver education resourcesProgress check-inOther

What outcome would make this support helpful for the family or student?(optional)

10Consent and Acknowledgment

I understand this intake is used to gather information for educational resource planning and referral coordination.I understand Kaleidoscope Kollege may recommend educational tools, parent resources, student support strategies, or referral options based on the information provided.I understand this form does not replace medical care, therapy, legal advice, emergency support, special education evaluation, or formal school eligibility decisions.I give permission for Kaleidoscope Kollege to contact me about this referral and next steps.I understand that additional consent may be required before Kaleidoscope Kollege communicates with a school, provider, agency, or outside organization.

Parent / guardian printed name(optional)

Relationship to student(optional)

Questions? Contact us

Fields marked required (guardian name, email, student name, and brief reason) must be completed. All other fields are optional but help us provide the most relevant support. Submitting this form does not guarantee services or create a formal service agreement.