<p>Student Assistance Team (S.A.T.) PRE-REFERRAL Information Form Ferguson Middle School</p><p>Primary Reason for S.A.T. Referral : ___ Academic ___ Behavioral ___ Emotional ___ Medical ___Other Describe the primary reason for referral:</p><p>Secondary Concerns:</p><p>Student Strengths, Talents, or Interests:</p><p>To Do List-Please complete the following before submitting:</p><p> Conference/Communicate with parent/guardian. Describe method(s), frequencies, and outcomes below:</p><p>*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:</p><p> Conference/communicate with other teachers or staff (e.g. tutor, aide, last year’s teacher, etc.). Describe key findings below:</p><p> Obtain information from school nurse and counselor to rule out/rule in related health or emotional issues. Describe key findings below:</p><p> 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:</p><p>Academic Performance: Grades Reading Ability Writing Ability Math Ability In-Class Activities Effort Homework Study Skills Class Participation Academic Honesty  Tests/Quizzes Other (explain)</p><p>Explanation:</p><p>Behavioral Issues: Won’t take responsibility Noncompliance w/ rules Defensive, Irritable Displays anger Argumentative Preoccupied with Violence Inappropriate Language Defiant Disruptive Other (explain)</p><p>Explanation:</p><p>Social/Emotional Issues: Quiet/withdrawn/isolated Change in Peer Group Lacks confidence Blames others Socialization problems Difficulty concentrating Preoccupied with Death Sadness/Crying Mood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)</p><p>Explanation:</p><p>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) </p><p>Explanation:</p><p>** 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: ______</p><p>Current Grades: Reading ______Math ______English ______Social Studies ______Science ______</p><p>Disciplinary Actions (List number of each this school year):</p><p>Demerits Detentions Saturday Schools ISS OSS</p><p>Accommodations, Modifications, and Interventions Please describe attempts to improve areas of concern:</p><p>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.</p><p>Accommodation Person(s) Responsible Effectiveness (1=low) Data or Other Notes 1 2 3 4 5</p><p>1 2 3 4 5</p><p>1 2 3 4 5</p><p>1 2 3 4 5</p><p>1 2 3 4 5</p><p>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.</p><p>Modification Person(s) Responsible Effectiveness (1=low) Data or Other Notes 1 2 3 4 5</p><p>1 2 3 4 5</p><p>1 2 3 4 5</p><p>1 2 3 4 5</p><p>1 2 3 4 5</p><p>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</p><p>1 2 3 4 5</p><p>1 2 3 4 5</p><p>1 2 3 4 5</p><p>1 2 3 4 5</p>