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Highline Public Schools
15675 Ambaum Blvd. SW Burien, WA 98166

Office Hours:

Monday-Friday: 7:30 a.m. - 4:30 p.m.

Highline Public Schools
15675 Ambaum Blvd. SW Burien, WA 98166

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Connection Center Referral

Required

Please complete the following form, and we will reach out to schedule the appointment. 
If you have the family with you, feel free to help the family schedule their Connection Center appointment using this link
Reason for Referral. Please select all that apply. requiredPlease select up to 7 choices
Please select up to 7 choices

Credit Recovery

Otherwise Please leave blank.

General Behavior

Select all that applyPlease select up to 5 choices
Please select up to 5 choices

Disengaged

Select all that applyPlease select up to 5 choices
Please select up to 5 choices

Long Term Suspended

Is the student currently serving a suspension or expulsion greater than 11 days?
Is the behavior record updated in Synergy to reflect the long-term suspension?
Please select the item below that best represents the incident for which the student was suspended. Please select up to 3 choices
Please select up to 3 choices
Was a threat assessment done?
Was law enforcement involved?
If the student has an IEP or 504, has a Manifestation Determination been initiated?
Must contain a date in M/D/YYYY format

Other

General Information

Referral Source Namerequired
First Name
Last Name
Student Namerequired
First Name
Last Name
Must contain a date in M/D/YYYY format
Is the student eligible for LRC services?

If a student is NOT eligible for LRC services, please invite the Connection Center counselor to an IEP meeting to brainstorm supports.

Who should we contact to set up an appointment?required
First Name
Last Name
Need Interpreter?
It is required that the person making a referral first contacts the family of the student. Has the parent/guardian or student contact given you verbal consent to make this referral?Referrals in which the family has not been contacted will be returned.
Referrals in which the family has not been contacted will be returned.
What interventions and/or resources have been utilized at the student’s current school to reengage the student? At least 5 interventions must be documented in order to move forward with a full-time placement.​​Please select up to 14 choices
Please select up to 14 choices
Do you have any safety concerns with this student?