PRE-REFERRAL Information Form

Student Assistance Team (S.A.T.) PRE-REFERRAL Information Form Ferguson Middle School

Primary Reason for S.A.T. Referral : ___ Academic ___ Behavioral ___ Emotional ___ Medical ___Other Describe the primary reason for referral:

Secondary Concerns:

Student Strengths, Talents, or Interests:

To Do List-Please complete the following before submitting:

 Conference/Communicate with parent/guardian. Describe method(s), frequencies, and outcomes below:

*Feel free to attach pertinent conference notes/emails to this form  Review student’s cumulative folder to determine ability/skill levels and prior interventions, grades, and test scores. Describe key findings below:

 Conference/communicate with other teachers or staff (e.g. tutor, aide, last year’s teacher, etc.). Describe key findings below:

 Obtain information from school nurse and counselor to rule out/rule in related health or emotional issues. Describe key findings below:

 Collect work samples or behavior logs/notes that demonstrate the primary reason for referral. Attach samples to this form before submitting. Describe baseline data below (e.g. SRI scores, frequency of behavior, Words read per minute, etc.): Please mark all areas of concern and describe as necessary:

Academic Performance: Grades Reading Ability Writing Ability Math Ability In-Class Activities Effort Homework Study Skills Class Participation Academic Honesty  Tests/Quizzes Other (explain)

Explanation:

Behavioral Issues: Won’t take responsibility Noncompliance w/ rules Defensive, Irritable Displays anger Argumentative Preoccupied with Violence Inappropriate Language Defiant Disruptive Other (explain)

Explanation:

Social/Emotional Issues: Quiet/withdrawn/isolated Change in Peer Group Lacks confidence Blames others Socialization problems Difficulty concentrating Preoccupied with Death Sadness/Crying Mood Swings Daydreams Other (explain)

Explanation:

Other Issues:  Weight Loss/Gain  Frequent Clinic Visits  Change in appearance  Bruises or marks  Tardiness  Frequent Absence  Many requests to Leave Sleeping in class  Other (explain)

Explanation:

** Please attach a copy of the student’s current schedule to this form Attendance so far this year: Days Absent: ______Days tardy to School: ______Early Dismissals: ______

Current Grades: Reading ______Math ______English ______Social Studies ______Science ______

Disciplinary Actions (List number of each this school year):

Demerits Detentions Saturday Schools ISS OSS

Accommodations, Modifications, and Interventions Please describe attempts to improve areas of concern:

1) Accommodations: Changes to the materials, settings, or student expectations that do not change the content of the lesson or correct the problem area. Examples: Books-on-tape, copies of notes provided, shortened assignments, questions read aloud, study carrel, extended time, special seating placement in class, schedule change, time out from class, dictate to a scribe, computer to type responses, oral responses, study guides, planner signed daily, timer, highlighter, preview questions before reading text, samples of teacher expectations, frequent progress reports, etc.

Accommodation Person(s) Responsible Effectiveness (1=low) Data or Other Notes 1 2 3 4 5

1 2 3 4 5

2) Modifications: Changes to the materials or student expectations that change the content of what is being taught. Examples: Different textbook/curriculum, easier assignments/tests, lower student expectations, calculator, etc.

Modification Person(s) Responsible Effectiveness (1=low) Data or Other Notes 1 2 3 4 5

1 2 3 4 5

3) Interventions: Activities done with the student to directly improve problem areas. Examples: tutoring, positive behavior plan, problem-solving activities, drill/practice, structured social skills practice, student-monitored checklist, help during advisory, learning contract, counseling sessions, peer tutoring/editing, repeated readings, paired readings, etc. Intervention Person(s) Responsible Effectiveness (1=low) Data or Other Notes 1 2 3 4 5

1 2 3 4 5