NEW REFERRAL to Special Education

Bering Strait School District REFERRAL FORM

Name of Student:______Date of Referral (mm/dd/yyyy):______

Age:______Birthdate (mm/dd/yyyy):______Gender:______Referred by:______Grade:______Site:______Teacher:______Parent/Guardian/Surrogate:______Work Phone:______Address:______Home Phone:______(Street/Box Number) ______(City, State, Zip) STUDENT INFORMATION SHEET

Days absent:______/______Days Suspended: ______/______(This year) (Last year) (This year) (Last year)

Grades Repeated: ______

Linguistic Background: Primary Language of Student: ______Primary Language of Home: ______

Screening Information: Vision: ______Pass/Fail Hearing: ______Pass/Fail (mm/dd/yyyy) (Circle one) (mm/dd/yyyy) (circle one)

Medications: ______

STUDENT RECORDS REVIEW

Roots/ SRI Results (in lexiles) What is this child’s tutoring schedule? ______Date ______Date ______Date ______How long has he/she received tutoring? ______Date ______

Reading Mastery Level Describe the success of interventions ______Date ______Date ______Date ______Date ______Reading Instructional Level ______Date ______Date ______Date ______Terra Nova Results (%ile) Date______Date ______Reading ______Language Arts______Bering Strait School District Mathematics ______Science ______Social Studies ______

Has this child been referred to the Solutions Team? Please describe findings. ______

Attach a copy of report cards. This year _____ Last year _____

Attach a copy of current evidence of performance. (As many as are applicable) Work samples _____ Developmental profile ______

REASON FOR REFERRAL: [ ] 1. Educational – Reading / Writing / Math [ ] 5. Behavioral/Social/Emotional [ ] 2. Communication – Speech / Language [ ] 6. Attendance/Tardy [ ] 3. Motor Skills – Fine / Gross [ ] 7. Homework [ ] 4. Hearing, vision, medical concerns [ ] 8. Daily Living Skills Please be specific in behavior terms: ______

______

Have the parents been contacted for the reason for referral? Yes ______No ______

STUDENT STRENGTHS: (inner attributes, things the child likes to do, positive resources, expectations to the behavior, or times when the problem does not occur) Bering Strait School District Revised: 5/29/07

PRE-REVERRAL INTERVENTIONS BY REFERRING TEACHER

Date Started ______Date Ended______Target Behavior/Learning Need: ______Describe Intervention: ______Outcome: data of outcome; rate of success ______Date Started______Date Ended______

Date Started ______Date Ended______Target Behavior/Learning Need: ______Describe Intervention: ______Outcome: data of outcome; rate of success ______Date Started ______Date Ended ______