Referral for Behavioral Consultations Services

Referral for Behavioral Consultation Services

*** Please send to Shelly Boutwell at Central Office Date of referral: ______Student’s Name: ______Date of Birth/ Age:______/______School: ______Grade: ______Student Disability: ______Teacher: ______School Contact: ______Title: ______Phone: ______Email: ______Planning Period/ Best time to reach: ______

Student strengths/interests:______

Reason for Referral (please be specific- duration, frequency, and intensity of 1-2 targeted behaviors: ______

Behavior Observation/ Consultation- when do these behaviors occur or occur most often? (lunch, recess, A.M./ P. M., specific class, etc.): ______

List specific questions or concerns you would like answered about this behavior: ______

List 3 interventions attempted or in place for 4-6 weeks: ______

Current Placement: Reg. Ed/ SAT/ Initial SPED Eval/ SPED resource/ SPED Collab/ SPED Self-Contained/ OT/ PT/ ST/ ESL/ group therapy/ indiv therapy

Classroom Management Plan in place? ___ yes ____no FBA conducted? ___ yes ____no Individual Behavior Plan in place? ___ yes ____no **If yes, please provide copy of plan, data, and length of implementation Is student prescribed medication (type and reason)? ___ yes ____no ______

Is student receiving outside psychological treatment? ___ yes ____no If yes, please provide:______

______School Contact Signature Date

______Special Education CO Building Contact Signature Date Instructions for Behavioral Consultation Services Referral

 Referrals are accepted and taken in order of priority and availability  Complete all questions or areas; referrals that are not complete will be returned for completion  Student strengths and interests are important in behavior planning development  Reason for referral must be specific including how often the behavior occurs, how long it occurs, and how intense the behavior is  When do the behaviors occur or occur most often? This determines the observation time  List any questions or concerns you have about the behavior  List at least 3 interventions that have been applied consistently for a 4-6 week period- if you do not have at least 3 or have only implemented the intervention for a week and dropped it, then you must meet with the student’s team and review the data  Circle all that apply to the student’s current placement  You must have your Special Education Building Contact sign off on the referral even if the student is NOT special education  The Special Education Building Contact may provide you with behavioral intervention assistance prior to referral completion or approval