SPECIAL EDUCATION REFERRAL FORM REASON FOR ...

Bering Strait School District
SPECIAL EDUCATION REFERRAL FORM
(To be completed after assistance from the Solution Team)
Student: Birthdate: Age: Grade: Site:
Parent/Guardian: Primary Language: English Other:
Address:
LEP Status:
Work Phone:
Referred by:
Home Phone:
Referral Date:
REASON FOR REFERRAL:
Check major area(s) of concern and briefly describe the child’s behavior, or performance in each area checked. If you
have identified more than one area of concern, circle the area you consider to be the highest priority.
Academic Reading Writing Math Pre-academic School Readiness
Cognitive
Social / Emotional
Communication
Behavioral
Motor Skills Fine Motor Gross Motor Activities of Daily Living
Health Related
Other (please describe)
Vision Hearing
Describe Specific Concerns:
SUMMARY OF EXISTING INFORMATION:
Solution Team Referral Date(s): Did child receive tutoring? Yes No
Parent Notification:
Has the parent/guardian been notified about your concerns regarding this student? Yes No
Date(s) parent/guardian was notified:
Prior Special Education Referral Date(s):
Prior Evaluations (may include):
Psychological Evaluation Date(s):
Educational Evaluation Date(s):
Communication/SLP Evaluation Date(s):
Physical/Medical Evaluation Date(s):
Screening Results(within the calendar year):
Vision Screening Date:
20/200 20/100 20/70 20/50 20/30 20/25 20/20
Other:
Follow-up
Hearing Screening Date:
Pass Refer
Follow-up
Attendance: Days absent this school year: Days absent last school year:
ATTACHMENTS:
Solution Team Referral Form
Parent Questionnaire
Documentation of interventions
Pre-Referral Interventions and Outcomes
Current evidence of performance. (Attach as many as are applicable)
Report Cards (current and last year )
Current Work Samples
Progress Report/Content Areas Levels
Statewide Assessment results
Teacher Observations/Narrative about concerns Tutoring data (interventions and outcomes)
SRI Results (lexile scores)
Early Screening Profile
Developmental Profile
Other:
Revised: 11/07

Bering Strait School District
SOLUTION TEAM INTERVENTIONS
Date Started __________Date Ended________
Target Behavior/Learning Need: __________________________________________________
Describe Intervention: ___________________________________________________________
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Outcome: data of outcome; rate of success __________________________________________
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Date Started __________Date Ended_________
Target Behavior/Learning Need: __________________________________________________
Describe Intervention: ___________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Outcome: data of outcome; rate of success __________________________________________
_______________________________________________________________________________
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Date Started __________Date Ended_________
Target Behavior/Learning Need: __________________________________________________
Describe Intervention: ___________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Outcome: data of outcome; rate of success __________________________________________
______________________________________________________________________________
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**Include additional pages as needed.