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 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): / 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?