Van Buren Intermediate School District

Bert Goens Learning Center

Student Referral Form

Date of Referral: ______

Reason for Referral:  New to District/Move-In  Change of Placement  Other: ______

Student’s Name: ______DOB: ______

Address: ______City: ______State:_____

Zip Code: ______Phone Number: ______Student’s Native Language: ______

Student Resides with:  Family Foster Parent Group Home Other:______

Student’s Certification on Current Eligibility Recommendation: CI SXI EI ASD ECDD  Other:______

Program Referred To:  AI  SXI  DD (If DD please indicate CI level):  MiCI  MoCI  SCI  ECDD

Referring District:______School :______

Name of Person Initiating Referral & Position: ______

Phone: ______E-mail: ______

Current/Previous School Placement: ______Name of School City, State

Currently in School Program?: Yes  No. Please Explain: ______

Parent/Guardian: ______Phone: ______

Bert Goens Learning Center Enrollment Process

  1. REFERRAL PROCESS:

The sending district initiates the referral process by contacting Susan Reynolds, Principal ( 539-5032) atthe Bert Goens Learning Center.

  1. The sending district will be asked to include the following documents with the STUDENT REFERRAL FORM.

Document / Date Received
Most recent Individualized Education Program
Most recent Eligibility Recommendation** and supporting reports:
Psychological Evaluation and Adaptive Behavior
Social Work Report
Speech and Language report including a Language Sample and the
PeabodyPicture Vocabulary Test-4 standard score
Occupational Therapy report including the Berry VMI
Physical Therapy report
Behavior Specialist report or Behavior Intervention Plan
Visually Impaired Teacher Consultant report
Audiogram or Audiologist’s report
Information about health concerns
Complete immunization records
Birth Certificate

**If Eligibility Recommendation is unavailable or not current within the last 3 years, the sending district will complete evaluations before the student can be referred to Bert Goens Learning Center.

  1. REVIEW OF RECORDS

The Principal or designee will review documentation and contact the local school district representative making the referral to discuss the enrollment status of the referred student.

C. STUDENT OBSERVATION

If the referral appears to be appropriate,a representative from the Bert Goens Learning Center will conduct an observation of the prospective student at his/her current placement.

  1. TOUR

A representative from the sending school will contact the parent/guardian with the outcome of the Referral Process. If enrollment at Bert Goens Learning Center appears to be an appropriate placement for the student, the parent/guardian must make an appointment with their child to tour the Bert Goens Learning Center. Staff at theBert Goens Learning Center who may be directly involved in the prospective student’s program will be introduced.If aBert Goens Learning Center placement seems likely, the parent/guardian will be given the enrollment packet at that time to complete then or return at a later date.

  1. IEPT MEETING

For students making a lateral transfer with a current IEP, the Transfer Of Student With A Disability –Part Bform must be completed.This form allows for a 30-day placement. Bert Goens Learning Center will convene an IEP Team meeting within 30 school days to develop an IEP.

The sending district must provide current documents and CA-60 file. If it is a 3-year IEP review, the new Review of Existing Educational Data( REED) and IEP with supporting reports must be included in the documentation. Students will not be allowed to attend the Bert Goens Learning Center until all required documents have been received.

  1. TRANSPORTATION

Transportation is arranged by the Bert Goens Learning Center.

Referral Information

Student: ______Date: ______

Name & Position of School PersonnelCompleting Questionnaire: ______

  1. List student health concerns:

______

  1. List medications taken by the student:

______

3.Does the student currently receive outside treatment from a physician, psychologist, psychiatrist and/or nursing staff? If yes, what type of treatment and how often?

______

  1. Is the student under any physician ordered restriction? If yes, please describe.

______

  1. Describe the student’s communication abilities including speech, sign language communication devices, communication boards, or assistive technology.

______

  1. Describe the parent/guardian involvement in this student’s educational planning.

______

  1. In what ways is the student independent?

______

  1. In what waysis the student dependent?

______

  1. Describe the interactions of this student with his/her peers and staff.

______

  1. Describe any student behavior(s) that interferes with instruction, stigmatizes,

Isolates, or endangers the student or other people.

______

  1. What concerns do the parents have regarding current or future educational issues?

______

  1. Describe the student’s special skills, strengths, and interests.

______

  1. Does this student require any adaptive equipment to access his/her day? ______
  1. What interventions have been tried and documented that warrants the team to make this referral?

______

  1. Describe specific concerns related to the needs of this student.

______

______

______

______

______

______

______

______

______

______

______

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