School Homeless Navigator Referral Form
McKinney Vento ARP-HCY I
Date
-
Month
-
Day
Year
Date
Who is Completing This Form?
*
Please Select
School Homeless Liaison
Other School Staff
OPC Care Manager
Youth or Family
Name of Referent
*
First Name
Last Name
Phone Number of Referent
*
Please enter a valid phone number.
Email of Referent
example@example.com
Legal Name of Student
*
First Name
Last Name
Preferred Name of Student
Student Date of Birth
*
-
Month
-
Day
Year
Date
Name of Parent/Guardian/Caregiver
*
First Name
Last Name
Caregiver Phone Number
*
Please enter a valid phone number.
Caregiver Email
example@example.com
School District
*
Please Select
Barnegat Township School District
Bay Head Borough School District
Beach Haven School District
Berkeley Township School District
Brick Township Public School District
Central Regional School District
Eagleswood Township School District
Island Heights School District
Jackson Township School District
Lacey Township School District
Lakehurst School District
Lakewood Township School Distric
Lavallette Borough School District
Little Egg Harbor Township School District
Long Beach Island Consolidated School
Manchester Township School District
Ocean County Vocational Technical School District
Ocean Gate School District
Ocean Township School District
Pinelands Regional School District
Plumsted Township School District
Point Pleasant Beach School District
Point Pleasant Borough School District
Seaside Heights School District
Southern Regional School District
Stafford Township School District
Toms River Regional School District
Tuckerton Borough School District
Name of School Student Attends
*
Student's Grade
*
Please Select
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Please describe the presenting need/challenge related to homelessness
*
Navigator Service Menu
Select the option(s) that apply below
1. NJ InCk
Enrollment NJ Integrated Care for Kids (NJ lnCK) -, Medicaid - homeless and non- homeless students. Medical/ Social evaluation and management.
2. K Hovnanian Children's Hospital
Enrollment Center for Vulnerable Children -K Hovnanian Children's Hospital (JSUMC)Homeless student (Medicaid Not Required) - comprehensive assessment medical/related services.
3. NJ Children's System of Care (CSOC
Performcare
CMO
FSO
FSC
DDD
DCPP
Service Agency Identification Assistance
*
Child Abuse Reporting
Counseling/Behavioral Health
Adolescent Shelters
Domestic Violence Shelter
Employment: Student or Parent
County Board of Social Services
SNAP or TANF
D.O.E. Mental Health Guide
Crisis Intervention Unit
Student Text/Phone Help Line
Household supplies
Pharmacy
Food Insecurities Donation Centers
Head Start Program locations
New Jersey Family Care Insurance
Social Security Office locations
Clothing Donation Centers
Energy Assistance Agencies
Housing
Health Insurance
Legal Services- Eviction or Utilities
Furniture
Dental
Vision
Hearing
Signature of Referent
*
Clear
Submit
Should be Empty: