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/notesthat demonstrate the primary reason for referral. Attach samples to this formbefore 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 Preoccupiedwith 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Social/Emotional Issues: Quiet/withdrawn/isolated Change in Peer Group Lacks confidence Blames others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 studentexpectations 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
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5

2) Modifications: Changes to the materials or studentexpectations 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
1 2 3 4 5
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
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5