MOCK FOLDER COLLEGE

THE FOLLOWING SHEETS
GO ON THE LEFT SIDE OF YOUR

FOLDER IN THAT ORDER.

ON THESE SHEETS, LOOK FOR THE BRIEF
HIGHLIGHTED GUIDANCE TO READ.

REVIEW THE STUDENT
FOLDER CHECKLIST FOR

FULL DETAILS.

REMEMBER… wherever you
write/type the Student ID, you must

add the prefix to the ID (the ID is
always 9 digits long for
CIS documentation).

Student Folder Checklist 2022-2023

Student Name: ___________J_o_se_p_h__in_e_S_c_h_m__o______________________
Student ID: ___________7_7_7_3_4_3_5_6_7______________________________

Left Side of the Folder

__________ 1. Student Folder Checklist (THIS FORM)

__________ 2. Student Recommendation (Optional; Only if Received on Paper)

__________ 3. Consent/Release of Information (Original Mandatory)

__________ 4. Student Profile (Original Mandatory)

__________ 5. Registration, Assessment, and Service Plan Summary (Print Out From
__________ 6. Bluebonnet – “Student Registration and Assessment Information” Report)

 End of Year Outcome Form (Print Out From Bluebonnet – “Student Outcome”
__________ 8. Report)

Student Survey Score Report and Responses (Print Out Emailed Report if
Administered Digitally)

__________ Pre

__________ 9. __________ Post
CIS Staff Faculty Survey (Print Out Emailed Report if Administered Digitally)

__________ Pre

__________ Post

Right Side of the Folder

__________ 1. Service Logs (Print out Completed Service Logs from Bluebonnet at
Outcomes Only)

__________ 2. Grade Reports from Campus Database (Most Recent On Top)

No other information, aside from what is listed above, may be included
in this folder, unless specifically authorized by the Director of Q&S.

LEFT SIDE OF FOLDER

____ Fall 2022
____ Spring 2023
____ Summer 2023

Student Recommendation Form

Campus Name and Code: _L__S__C_-_T__o_m__b__a_l_l__9__9_9__-_8_3__5___ Student ID: ____7__7_7__3__4__3_5__6_7______

Student First Name: ____J_o_s_i_e__________________ Last Name: _____S__c_h_m___o_________ COLLEGE

Please let us know why you were referred to us today. Provide as much information as possible to assist in determining how CIS can better
serve you. Please be aware that you may be served at school or referred to an outside agency for services.

 Academics (Course work, Academic Readiness, Participation)__________________________________________________________

_________

 Attendance (Absences, Tardies)

________________________________________________________________________________________________

 Behavior (Mental Health, Self-Esteem, Family Conflict, ETC.)

___________________________________________________________________________

 Social Service Needs (Food/Housing, Financial Lit, Health, ETC.)

_________________________________________________________________________

How did you hear about CIS?  01-CIS Staff  03-Self Recommendation  07-Peer  09-Parent

 31-Law Enforcement  33-Student Services  35-Professor  37-Campus Administrator
 43-Academic Advisor
 39-Financial Aid Office  41-Learning Center  45-Business Office

 32-Other: ____________________________________

Jo Schmo Josie SchmoStudent Signature: ___________________________________ Printed Name: _________________________________ Date:_9__-__2__3__-__2__2_____
(Signature must be in ink)
Please submit this form to the CIS office. Thank you.

CIS Use Only

Verbal recommendation taken from (NAME): _____________________________________________________________
Date________________ CIS Staff Initials________________

Follow-up Note: ____________________________________________________________________________
__________________________________________________________________________________________

Kristin Carpenter 09/23/2022

10631 9-23-20CIS Staff Signature: _________________________________________ Staff Code:__________________ Date: _________________________
(Signature must be in ink)

LEFT SIDE OF FOLDER COLLEGE STUDENT CONSENT / RELEASE OF INFORMATION # CI20-2

Campus Name: ___J_o_L_s__iS_e__CS__-__cT_h_o__mm___o_b__a__l_l_________S___c_h__o__o___l__Y___e__a__r_2022-CS20tau2md3epnuts Code: __9_9_9_-_8_3_5__________________
Student Name: ID:__7__7_7_3_4__3_5_6_7_________________

Consent to Participate:
1. I agree to participate in the Communities In Schools (CIS) program for the 2022-2023 school year. The services may include but are not

limited to supportive guidance/counseling, educational support, tutoring, mentoring, enrichment activities, referrals to other agencies,
and other:______________________________.

2. I acknowledge that I will complete surveys and/or assessments administered by CIS to guide service planning and determine progress. I
also give permission for CIS to use [on an anonymous basis] the responses to surveys and/or assessments in promotional materials and
content for CIS

3. I acknowledge that this consent is voluntary and may be revoked at any time by informing CIS staff, in writing, except that prior consent
will still apply to the extent that agencies have already acted in reliance of it.

4. I agree to participate in field trips and other activities sponsored by CIS. Private transportation may be used in these and other activities.
5. I give permission for routine or emergency medical or dental treatment by any licensed medical doctor to be provided in the event of

illness or accident if I am unable to do it myself.

Consent to Release of Information:
6. I give permission for CIS to provide and obtain the following information from the College: demographics, grade reports, attendance

records, test scores, class schedules, identification numbers, health-related information, special education information, interventions and
services provided, and other:____________________.

7. I acknowledge that the information provided and obtained may be used to plan and adjust services for me, for tracking and reporting
purposes, and to evaluate and determine the effectiveness of the CIS program.

8. I acknowledge that the records and information released under this consent will be kept confidential to the extent permitted by law and
used only for the purpose indicated.

9. I acknowledge that the release of records under this consent is subject to any limitations placed by federal and state law.
10. I acknowledge that this consent allows release of data for the school year listed above. Data from this year will be retained for up to five

seven years and may be shared during that time for evaluation purposes or to provide services that will help me.

11. I acknowledge that the records released concerning the student may contain references to other persons (i.e., members of the student’s
family).

12. I understand that the data and information collected on me including documentation of services provided to me is maintained in a secure
computer database and a case file. I authorize CIS to maintain the information provided for the purposes noted above in the CIS computer
database and case file.

13. I acknowledge that I have the right to inspect or obtain a copy of any record released by this consent upon request in writing to the
releasing agency, subject to any applicable copying costs and legal limitations.

14. In addition, I give permission for CIS to provide and/or obtain the above information and other information noted below from the following
individuals or organizations:
_____________________________Individual/Organization _____________________________Individual/Organization

15. I acknowledge receipt of the CIS Participant Rights.

CIS may use my image as explained herein. I understand that CIS may take and use photographs, digital or other recordings, or other images
of me participating in the Program as part of its fundraising and marketing efforts. I consent to CIS’s use of my image for these and similar
purposes, whether in printed materials, on the Internet, or in any other medium, without any time limitation. I understand that CIS is not

obligated to compensate me for such use of my image. ☐ YES ☐ NO

My signature below authorizes CIS to provide the above types of information relating or referring to me and to my school and the
released agents (upon appropriate request) and also authorizes CIS to obtain such information from my school.

I release Communities In Schools and its employees, volunteers, or agents from liability for accidents, injuries, or illnesses that may occur

to me during my participation in the program. I understand that I am voluntarily participating in the Communities In Schools program.

Name (Please print): __J__o_s_i_e__S__c_h_m__o___________________________________________________________________
Address: _____1_3_2_0__R__o_u_n_d_a__b_o_u_t__R_d__. _____________ City: _______T_o_m__b_a_l_l_____, TX, County
Zip: _7_7_3__7_5___

PSihgonnaet:ur_e_:_________________2__8___1__-_7____9__J8__o-__8__S__3__c8__h3___m___o________________________P_h_o_n_e__Ty(Spieg:nature☐mCuestllbe in ☐ Home ☐ Work
ink) Date: __________9__/_2_3__/_2_2_

Emergency Contact Name: ___M__o_’n_i_q_u_e__S__c_h_m__o____________________ Phone: 281-798-8383

ECmISeSrgtaefnfcSyigCnoanttuarcet:R_e_l_a_t_iKo_n_rs_ihs_it_pi_nt_o_CS__tau_rd_pe_ne_tn_:_t_e_r_________M___o___m__S_t_a_f_f_C_o_d_e_:_______1____0__6____3____1____D__a_t_e_R_e_c_e_i_v_e_d_: __________9__-__2____3____-__2___2_____

© 2019 Texas Education Agency Updated: July 2022 Page 1 of 1

LEFT SIDE OF FOLDER

2022-09-18T08:47:15+00:00 UTC

2022-2023

LSC – Tomball (999-835)

2022-2023

[email protected]

September 29,2022

Josie
Schmo
(281) 798-8383

343567
1320 Roundabout Road
Tomball
77375

(281) 798-9393
Mo’nique Schmo
Mother

[email protected]

Student Profile 2022-2023 LEFT SIDE OF FOLDER

Campus Name Lsc-Tomball
Campus Code
999-835

JosieStudent Name (first) Schmo(mi) (last)

COLLEGE

Name of High ____________Tomball HS_________ School ___Tomball ISD_____ Year of HS 2023
School: District: Graduation

Student Information Gender 1 Male 7 Female 9 Other Ethnicity (required) Race (select all that apply)
1 American Indian/Native Alaskan
Date of Birth 4 / 27 / 2003 1 Hispanic/Latino 2 Asian
OR
(Check ONE) 1 English 3 Spanish 2 NOT Hispanic/Latino 3 Black/African American
5 Native Hawaiian/Other Pacific Islander
HomeLanguage 6 White
8 Other
5 Vietnamese 9 Other: ___________

The Student Lives WITH: (Check ALL that apply) The Student Lives WHERE: (Check ONLY ONE)

35 Partner or Spouse 1 Immediate Family Home 10 Emergency Shelter
3 Other Relative's Home 13 Other Perm. Shelter
1 Mother 3 Father 5 Motel 15 Detention Facility
7 Halfway House 21 Non-Relative's Home
7 Grandmother 12 Other Relative 9 Residential Placement 23 Homeless
25 Campus Housing
9 Grandfather 16 Legal Guardian

14 Foster Parent 31 Independent

18 Step Parent 33 Non-Relative

Family Information __ Yes __ No : Female Head of Household (Unmarried woman who 1Number of people living in the household __ __
pays more than 50% of costs for mom and her dependents)

Assistance Special Characteristics 35 Previously Incarcerated
(Check ALL that apply to student and family) (Check ALL that apply) 37 First Generation College Student
39 Disability Services
99 None 4 Migrant Family 41 Employed Full Time
8 Homeless 43 Employed Part Time
4 Public Housing 24 WIA Participant 9 Foster Care 44 Veteran
6 SSI 25 CHIP 10 Physical Disability 30 None
8 Food Stamps 27 Financial Aid 25 Parenting/Pregnant
11 Medicaid 28 Natural Disaster 51 Unschooled, Asylee or Refugee
13 WIC
33 Active Military
50 Immigrant

Student's Country of Origin:

LEFT SIDE OF FOLDER

JOSIE SCHMO LSC - Tomball
999-835
777343567
COLLEGE 2022 - 2023

Student Information Recommendation

SSN/PEIMS/TUID 4/27/2003 Recommendation 9/23/2022
Date of Birth Female Date
Not Hispanic Kristin Carpenter
Gender Other Case Assigned To Self
Ethnicity English
Recommendation Self Referral
Race Employed Full Time Source Academics
Primary Language Attendance
Relationship Behavior
Special Social Services
Characteristics Reason

Eligibility

Criteria Mental Health

Family Profile Assessment & Service Plan

Lives Where Immediate Family Home Assessment Date 10/1/2022
Number in 1 Educational Goal
Household Enrollment in 4-yr University or
Lives With Independent College
No
Female Head of Barriers To Success Plan
Household Financial Aid
Behavior Mental Health 100
Public Assistance 200

Consent & Contact

Consent Date 9/30/2022
Photo Consent Yes

Parent Name Mo’nique Schmo
Address 1320 Roundabout Rd.
Tomball, TX 77375

Contact Number 2817988383

LEFT SIDE OF FOLDER

Communities in Schools Houston, Inc: End of Year Outcome

School Code and Name: 999-835 LSC - Tomball Grade Level: COLLEGE
Student ID and Name: JOSIE SCHMO (777343567) Assessment Date: 10/1/2022
N/A
TUID: Update Date:

Assigned To: 10631 Kristin Carpenter
Semester: FALL 2022

Termination Date: 12/31/2022 Reason: 999-End of Semester

Improvement in assessed areas:
1 = improved; 2 = no change; 3 = got worse
*** = Added on Update Date

Behavior Improved
13 Mental Health 1

Did student complete all courses taken with a C or better?
KEY: S=Successfully Completed; U=Unsuccessful Attempt; NA=Not Applicable

S For Credit -- Developmental -- Other
Progress 3 For Credit hours attempted

3 For Credit hours earned

0 Developmental hours earned 0 Developmental hours attempted

3 Total hours earned 3 Total hours attempted

KEY: S=Successfully Completed; U=Unsuccessful Attempt
U 5 - Enrollment in 4-yr University or College

U 7 - Transfer Credit to Another Institution

Kristin Carpenter

CIS Staff Signature ________________________________________ Date: 6/3/2023

LEFT SIDE OF FOLDER

From: Q & S <[email protected]>
Sent: Tuesday, December 14, 2022 11:54 AM
To: Kristin Carpenter
Subject: Student Survey Score Report - Josie Schmo

CAUTION: This email originated from outside of the organization. Do not click links or open attachments
unless you recognize the sender and know the content is safe.

Josie Schmo

Tomball
Taken: 9/24/22

Score: 60%

Emotional Wellness

Understanding your own feelings and expressing emotions in a constructive way, and having the ability to deal with stress and cope with life’s
challenges

I am able to maintain a balance of work, family, friends and other obligations.
Sometimes

I am resilient and can bounce back after a disappointment or problem.
Sometimes

I am able to make decisions with minimal stress or worry.
Rarely

I am flexible and adapt or adjust to change in a positive way.
Rarely

I find it easy to express my emotions in positive, constructive ways.
Rarely

I recognize when I am stressed and take steps to manage my stress (e.g., exercise, quiet time, meditation).
Rarely

When I am angry, I try to let others know in non-confrontational or non-hurtful ways.
Sometimes

Environmental Wellness

Recognizing the interactions between yourself and your environment (natural and social), responsibly using available resources, and fostering a
safer and healthier environment for others

I surround myself with people who support me in my journey of being healthy and well.
Rarely

I am aware of and make use of campus health, and wellness, and safety resources.
Rarely

Intellectual Wellness

engaging in creative and mentally-stimulating activities, expanding your knowledge through cultural, artistic, or skill-based learning, and sharing
knowledge and skills with others

I can critically consider the opinions and information presented by others and provide constructive feedback.

Never

I enjoy learning about subjects other than those I am required to study/in my field of work.
Rarely

I manage my time well, rather than it managing me.
Sometimes

Occupational Wellness

Getting personal fulfillment from your job or academic pursuits, and contributing to knowledge and skills, while maintaining a work-life balance

I balance my social life and job responsibilities well.
Sometimes

My work load is manageable.
Sometimes

Physical Wellness

Making choices to avoid harmful habits and practice behaviors that support your physical body, health and safety

I engage in physical exercise regularly (eg 30 minutes at least 5X a week or 10,000 steps daily).
Rarely

I avoid using tobacco products or other drugs.
Sometimes

I abstain from drinking alcohol; or if I do drink, I aim to keep my BAC less than .06.
Usually

I eat a balanced diet (fruits, vegetables, low-moderate fat, whole grains).
Sometimes

I get regular physical exams (i.e. annual, when I have atypical symptoms).
Rarely

I get 6-8 hours of sleep each night.
Rarely

Social Wellness

Building and maintaining a diversity of supportive relationships, and dealing effectively with interpersonal conflict

I participate in a wide variety of social activities and find opportunities to form new relationships.
Never

I feel supported and respected in my close relationships.
Rarely

I consider the feelings of others and do not act in hurtful/selfish ways.
Sometimes

Spiritual Wellness

Having beliefs and values that provide a sense of purpose and help give meaning and purpose to your life, and acting in alignment with those beliefs

I feel like my life has purpose and meaning.
Rarely

I take time to think about what's important in life - who I am, what I value, where I fit in, and where I am going.
Rarely

LEFT SIDE OF FOLDER

From: Q & S <[email protected]>
Sent: Tuesday, September 24, 2022 11:54 AM
To: Kristin Carpenter
Subject: Student Survey Score Report - Josie Schmo

CAUTION: This email originated from outside of the organization. Do not click links or open attachments
unless you recognize the sender and know the content is safe.

Josie Schmo

Tomball
Taken: 9/24/22

Score: 58%

Emotional Wellness

Understanding your own feelings and expressing emotions in a constructive way, and having the ability to deal with stress and cope with life’s
challenges

I am able to maintain a balance of work, family, friends and other obligations.
Sometimes

I am resilient and can bounce back after a disappointment or problem.
Rarely

I am able to make decisions with minimal stress or worry.
Rarely

I am flexible and adapt or adjust to change in a positive way.
Rarely

I find it easy to express my emotions in positive, constructive ways.
Rarely

I recognize when I am stressed and take steps to manage my stress (e.g., exercise, quiet time, meditation).
Rarely

When I am angry, I try to let others know in non-confrontational or non-hurtful ways.
Sometimes

Environmental Wellness

Recognizing the interactions between yourself and your environment (natural and social), responsibly using available resources, and fostering a
safer and healthier environment for others

I surround myself with people who support me in my journey of being healthy and well.
Rarely

I am aware of and make use of campus health, and wellness, and safety resources.
Rarely

Intellectual Wellness

Engaging in creative and mentally-stimulating activities, expanding your knowledge through cultural, artistic, or skill-based learning, and sharing
knowledge and skills with others

I can critically consider the opinions and information presented by others and provide constructive feedback.
Never

I enjoy learning about subjects other than those I am required to study/in my field of work.
Rarely

I manage my time well, rather than it managing me.
Sometimes

Occupational Wellness

Getting personal fulfillment from your job or academic pursuits, and contributing to knowledge and skills, while maintaining a work-life balance

I balance my social life and job responsibilities well.
Sometimes

My work load is manageable.
Sometimes

Physical Wellness

Making choices to avoid harmful habits and practice behaviors that support your physical body, health and safety

I engage in physical exercise regularly (eg 30 minutes at least 5X a week or 10,000 steps daily).
Rarely

I avoid using tobacco products or other drugs.
Sometimes

I abstain from drinking alcohol; or if I do drink, I aim to keep my BAC less than .06.
Usually

I eat a balanced diet (fruits, vegetables, low-moderate fat, whole grains).
Sometimes

I get regular physical exams (i.e. annual, when I have atypical symptoms).
Rarely

I get 6-8 hours of sleep each night.
Rarely

Social Wellness

Building and maintaining a diversity of supportive relationships, and dealing effectively with interpersonal conflict

I participate in a wide variety of social activities and find opportunities to form new relationships.
Never

I feel supported and respected in my close relationships.
Rarely

I consider the feelings of others and do not act in hurtful/selfish ways.
Sometimes

Spiritual Wellness

Having beliefs and values that provide a sense of purpose and help give meaning and purpose to your life, and acting in alignment with those beliefs

I feel like my life has purpose and meaning.
Rarely

I take time to think about what's important in life - who I am, what I value, where I fit in, and where I am going.
Rarely

LEFT SIDE OF FOLDER

From: Q & S <[email protected]>
Sent: Tuesday, October 1, 2022 12:00 PM
To: Kristin Carpenter
Subject: CIS Staff Response Report - Josie Schmo

CAUTION: This email originated from outside of the organization. Do not click links or open attachments
unless you recognize the sender and know the content is safe.

Josie Schmo

Tomball
CIS Staff Respondent: Kristin Carpenter
Taken: 10/01/2022

Score: 59

Behavior Performance
Academic Readiness
N/A

Language (ESL/LEP)
N/A

Emotional Crisis Coping
N/A

Mental Health Maintenance
Skills Demonstrated with Minor Mistakes

Grief & Loss Coping
N/A

Family Conflict Management
N/A

Self Esteem
N/A

Social Skills
N/A

Pro Social Skills & Civic Engagement
N/A

Career Readiness
N/A

Financial Literacy
N/A

Life Skills
N/A

Social Service Access
Basic Needs
N/A

Day Care
N/A

Employment
N/A

Health
N/A

Housing
N/A

LEFT SIDE OF FOLDER

From: Q & S <[email protected]>
Sent: Tuesday, December 17, 2022 12:00 PM
To: Kristin Carpenter
Subject: CIS Staff Response Report - Josie Schmo

CAUTION: This email originated from outside of the organization. Do not click links or open attachments
unless you recognize the sender and know the content is safe.

Josie Schmo

Tomball
CIS Staff Respondent: Kristin Carpenter
Taken: 12/17/2022

Score: 60

Behavior Performance
Academic Readiness
N/A

Language (ESL/LEP)
N/A

Emotional Crisis Coping
N/A

Mental Health Maintenance
Skills Demonstrated Consistently without Mistakes

Grief & Loss Coping
N/A

Family Conflict Management
N/A

Self Esteem
N/A

Social Skills
N/A

Pro Social Skills & Civic Engagement
N/A

Career Readiness
N/A

Financial Literacy
N/A

Life Skills
N/A

Social Service Access
Basic Needs
N/A

Day Care
N/A

Employment
N/A

Health
N/A

Housing
N/A