Lenape Elementary School

New Paltz Central School District Referral to Instructional Study Team Lenape Elementary Student Name: Grade: Date of Birth: Parent/Guardian: Address: Telephone: Referred by: Referral Date:

Is this student an English Language Learner? _____Yes ____ No

Prior IST Meetings (Grade + Month)

Reading Recovery Met Benchmark Did not meet Incomplete Program First grade only Benchmark

Remedial Reading K 1 2 3 4 5 Services

1. Reason for Referral (check as many as appropriate): _____ A. General academic concerns _____ B. Reading _____ C. Math _____ D. Written Expression _____ E. Fine Motor (i.e. Handwriting, cutting, etc.) _____ F. Speech/Oral Language _____ G. Social/Emotional/Behavior concerns (Please indicate your interest in having a member of the Crisis Team present _____ yes _____ no). _____ H. Work Habits _____ I. Attendance _____Absent ____ Tardy _____ Leaves Early _____ J. Listening skills _____ K. Others (please be specific) ______

2. Are you aware of any physical or medical problems which may affect the student’s functioning at school?

3. An administrator, regular education teacher, special education teacher and social worker will be attending the IST meeting. Please indicate on the following list any other support staff you would like present.

_____ Remedial Reading Teacher _____ Occupational Therapist

____ Speech/Language Teacher ______School Psychologist

_____ ESL _____ School Nurse _____ Other______

Please indicate any of the above staff with whom you have consulted, if any:

4. Please describe the student’s performance in the following areas. Be sure to include most recent test scores (i.e., NYS ELA, NYS Math, etc.), and all other assessment data:

Subject Area Reading

NYS ELA Test Score: _____ Date/Grade Taken: ______

NYS Math Test Score: ______Date/Grade Taken: ______

5. Areas of Concern: (Please mark any that apply)

Academic Issues: Reading: ___Weak literal comprehension ___Weak Vocabulary ___Difficulty with phonics (omits, adds, substitutes, reverses letters, words or sounds when reading) ___Difficulty with fluency ___Reads below grade level

Writing: ___Difficulty with organizing written work ___Difficulty with mechanics of writing ___Difficulty with spelling ___Difficulty with written expression

Language: ___Difficulty expressing ideas verbally ___Needs questions or directions repeated ___Difficulty understanding abstract concepts

Math: ___Difficulty memorizing facts ___Weak calculation skills ___Difficulty with Multi-step problems ___Difficulty with reading impacts word problems

Organization: ___Does assignments/cannot find them ___Does not write down assignments ___Does not complete homework ___Comes to class without materials Behavioral Issues: ___Distractibility ___Impulsivity ___Social skills ___Non-compliance ___Aggression ___Insubordination ___Other:______

Psychosocial or Mental Health Concerns: ___Depression ___Suicidal thoughts/ideations ___Self-injurious behaviors ___Grief ___Self Esteem ___Anxiety ___Family Issues ___Peer difficulties ___New student having trouble with adjustment ___School Avoidance Other:______

Health Concerns:______Attendance: _____Frequently Absent ____ Frequently Tardy _____ Leaves School Early

6. Strengths: (Please check all that apply)

___Organized ___Math ___Good Study skills ___Good Writing Skills ___Friendly ___Reading ___Cooperative ___Good Verbal Skills ___Kind ___Artistic ___Musical ___Athletic ___Other:______

7. Are there certain activities that the student prefers to do/tends to excel at?

Procedural Check List:

When was contact made with the parent/guardian to discuss your concerns? ___/_____/____ What was the parent’s feedback?______

8. Did you inform the parent that you would be referring the student to IST? _____Yes______No

9. An administrator, social worker, classroom teacher and special education teacher will be present. Please indicate on the following list any other support staff you would like present.

______Speech Therapist ______Reading Teacher ______ELL Teacher ______Occupational Therapist ______Physical Therapy ______School Psychologist ______School Nurse ______Additional Classroom Teacher ______Other ______

______

Please indicate any of the above staff with whom you have consulted, if any: ______

______

10. What measures have you taken to assist the student? (Please describe at least 3)

Specific Strategy Implemented in the Classroom Frequency Beginning Ending Tier I and Performance Performance duration Small group instruction Targeted intervention based on similar needs

Guided Reading

1.1 Instruction 1-2 Targeted intervention based on similar needs

Graphic Organizers

Study Buddy

Positive Reinforcement

Language: Break down for understanding Check for comprehension Visual supports

Behavioral: Planned ignoring Preferential Seating Behavioral Checklist Reward System Planned Breaks Other

Behavior Intervention Plan

Breaking down tasks

Modified class work

Other (describe): Additional Comments:

11. What additional school and/or community resources have been used to assist this student?

Support Service Frequency Comments SUNY Literacy Program

Remedial Reading

Multisensory Approach

Supportive Counseling

OT/Sensory support

Reading Software

Summer School

Outside Tutoring

Speech and Language Services

Community Resources (list):

Other (describe):

12. Have you discussed your concerns with this student’s parents (describe nature of support)? Yes __ No__

13. What would you like to see happen as a result of this referral to the Instructional Study Team? ------TO BE COMPLETED BY INSTRUCTIONAL STUDY TEAM------

INSTRUCTIONAL STUDY TEAM PLAN

Date: Is this a revisit? Does this case need to be revisited? YES_____ NO_____ If yes, the revisit date will be: Will student be referred to CSE? YES____ IF YES, ENTER DATE______NO_____ Members Present: Background Information:

Student Needs/Goals:

STRATEGIES TO ACCOMPLISH THESE GOALS

* Person taking IST minutes, please initial here: _____ Intervention Implementation Frequency Time Start Date Progress Documentation Who? Where? Frame

IST Liaison______Check-in date______