Bering Strait School District
SPECIAL ED REFERRAL FORM
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.
Reading Writing Math / Pre-academic School Readiness
Cognitive / Social / Emotional
Communication / Behavioral
Motor Skills / Fine Motor Gross Motor / Activities of Daily Living
Health/Medlical / Other (please describe)
Vision Hearing
Describe Specific Concerns:
SUMMARY OF EXISTING INFORMATION:
Solution Team Referral Date(s): / Did child receive tutoring? Yes NoParent 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): / Communication/SLP Evaluation Date(s):
Educational Evaluation Date(s): / Physical/Medical Evaluation Date(s):
Screening Results(within the calendar year):
Vision Screening Date:
20/20020/10020/7020/5020/3020/2520/20
Other: Follow-up / Hearing Screening Date:
PassRefer
Follow-up
Attendance: / Days absent this school year: / Days absent last school year:
ATTACHMENTS:
Intervention Data (indicating intervention outcomes) / Parent Questionnaire
Interventions used and Outcomes / Pre-Referral Interventions and Outcomes
Solution Team Documentation / Social/Emotional Worksheet (if applicable)
Current evidence of performance. (Attach as many as are applicable)
Report Cards (current and last year ) / Current Work Samples indicating areas of concern
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: 8/10
PARENT QUESTIONNAIRE
Child’s Legal Name M or F Date of Birth
Tell me some things about your child that will help me to know him/her.
Does your child have brothers or sisters? Yes or No
Name Age
Name Age
Name Age
Name Age
Name Age
What are your child’s favorite indoor activities?
What are your child’s favorite outdoor activities?
What responsibilities or chores does your child have?
What was the first language learned by your child?
What languages are spoken at home?
Does your child have asthma? Yes or No
Does your child have allergies that could be a problem at school (e.g. foods, pets, pollens, insects)?
No Yes If “Yes”, what kind?
Date of last completed: Physical Exam Dental Exam
Vision: No known problem
Had professional eye check-up
Needs glasses: all the time for reading
May need medicine during school hours: Daily/Regular Occasionally
The Bering Strait School District requires that forms be completed by your physician when it is necessary for children to take medication during school hours. Please see the principal if medication is to be taken a school.
Hearing Concerns: No Yes Sometimes Seat in front
Frequent ear infections? Yes or No as a baby still
Has ear tubes? Yes or No has had ear tubes times
Has a problem with hard wax? Yes or No
Has hearing aid(s)? Yes or No
Has any member of the immediate family experienced difficulties with reading, speaking, spelling, writing, or math?
Is your child able to:
Tie shoes? Yes or No Button? Yes or No Dress self? Yes or No
Ride tricycle? Yes or No Ride bicycle? Yes or No Zip coat? Yes or No
My child is: right handed left handed hasn’t decided
School History:
Has your child attended another school? Yes or No When? Where?
Social and behavioral history:
Do you have any special concerns about your child’s behavior in any of the following areas?
Listening/Paying attention Fears
Speech/Language Toileting
Sleeping Discipline
Eating Other
Please check any of the following that usually apply to your child:
Gets along well with others Shares Quick to anger
Acts shy Acts without thinking Clumsy
Misunderstands Easily frustrated Cries easily
Is always moving Head banging Bossy
Doesn’t follow instructions Rocking Difficult to soothe
Accident prone Takes turns
Tries new activities Sits and listens to a story for 10 minutes
Doesn’t listen Moves easily from one activity to another
Prefers quiet activities Plays independently for 5-10 minutes
Plays cooperatively with others Listens without interrupting while someone else is talking
Are there any problems that may impact learning?
Is there any other information that will help me to better understand your child?
What would you like your child to learn this year?