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CHILD/YOUTH INFORMATION / Last Name: / First Name: / Grade:
Date of Birth: (dd/mm/yyyy) / Male Female / Program Unit Funding (PUF): Yes
Address:
PARENT/LEGAL GUARDIAN INFORMATION / Last Name: / First Name: / Parent Legal Guardian
Contact: Home: / Cell: / Work:
Email:
Last Name: / First Name: / Parent Legal Guardian
Contact: Home: / Cell: / Work:
Email:
REFERRER’S INFORMATION
(select either Agency, Private ECS or School) / Agency Private ECS School, specify School District:
Organization/School Name:
Referrer’s Name / Title: / Phone: / Ext
Teacher’s Name: / Phone: / Ext
Date: (dd/mm/yyyy) / Email:
This request has been discussed with the School Administrator No Yes N/A
The parent or legal guardian agreed to this request for consultation on Date: (dd/mm/yyyy)
REQUESTED / REPORT
(Required) / APPENDIX
(Attached) / School jurisdiction:
1. Submit to Central Office for approval:
Grasslands: Patti Jones or Brigitte Gerrard
MH76:
PRSD:
MHCBE:
CTR:
2. Central Office: forward to Regional Manager & appropriate service provider
Consultant- Hearing Services
/ Attach
Audiogram / A
Teacher- Vision Services
/ Attach either:
Ophthalmology or
Optometry report / B
Other (Agency, Private or Independent):
1. Submit to RCSD Regional Manager
call 403-866-3032 if you have any questions about this form/process
Physiotherapy / N/A / C
Assistive Augmentative Communication (AAC)
/ AAC SLP and OT consultations are available without a request form. Access is through the school- linked SLP or OT. / Please advise Central Office representative of involvement.
The information on this form is being collected under the Health Information Act and/or the Freedom of Information and Protection of Privacy Act for the purpose of recording consent to the disclosure of health information and/or personal information. For questions about this collection of information, contact Donna Balas, Regional Manager SE RCSD at or call 403-866-3032.
Updated – Sept. 2, 2014 2
Appendix A –Deaf/Hard of Hearing
A. The child/youth:Has been diagnosed with a hearing loss (audiogram attached)
Wears amplification: Cochlear Implant Hearing Aid
Uses a sign system: American Sign Language Signed Exact English Other
Has an interpreter
B. Learns via listening and speaking (check all that apply)
Frequently asks for things to be repeated
Struggles to communicate with peers
Struggles to communicate with teacher / EA
Is struggling academically
Struggles to follow directions/answer questions
Has difficulty telling a story
Has difficulty making grammatically correct sentences
Comments: / Learns using Sign Language (check all that apply)
Struggles to engage with peers
Has a peer group at school
Struggles to communicate with teacher /EA
Is struggling academically
Struggles to follow directions/answer questions
Has difficulty telling a story
Has a good relationship with the interpreter
Comments:
C. Reason for request:
D. Child/youth strengths and interests:
E. What strategies have been tried? What strategies were effective?
F. Additional Information (include special needs):
G. How an Audiologist can help. (Alberta Health Services) Contact Jim Werner phone 403-528-8175
· Provide an audiogram (required to be attached to request for the Consultant for Deaf/Hard of Hearing)
· Determine if the child has hearing loss
· Determine if the type of loss requires medical evaluation
· Interpret assessment and hearing aid fitting information
· Provide trouble shooting support to parents regarding hearing aids and how they work/function
H. How a Consultant for the Deaf/Hard of Hearing can help.
· Recommend strategies, specialized learning materials and resources to support learning
· Consult regarding curricular modifications
· Provide information on sign systems (American Sign Language, Signed English) and in services related to beginner sign language
· Consult regarding social skill development
· Provide consultation regarding individualized programming to enhance auditory, academic, sign and/or oral language skills
· Provide inservices regarding the educational implications of a hearing loss and integration of deaf and hard of hearing students into the classroom
Completed By: / Parent(s) Professional Date) (dd/mm//yyyy
RCSD Request for Consultation – Appendix A
Appendix B –Blind/Visually Impaired
Alberta Education Number: mandatoryA. The child/youth:
Is registered with CNIB / Has limited visual acuity
Has low vision
Has recently experienced vision loss
Has a reduced field of vision / Is having difficulty with orientation and mobility
Needs appropriate reading and writing media
Is struggling with academic learning
Needs assistive technology
B. Reason for request:
C. Child/youth strengths and interests:
D. What strategies have been tried? What strategies were effective?
E. Additional Information:
F. The Consultant for the Blind/Visually Impaired can help with educational needs.
· Assess child’s functional vision to determine educational implications and programming
· Interpret medical eye reports as they relate to educational environments
· Consult regarding educational resources and adaptations
· Consult regarding educational strategies for learners with multiple needs
· Assess educational needs: academic, Braille, specialized equipment, functional academics
· Registration with SSVI (Specialized Services for the Visually Impaired). If child is eligible, recommend appropriate learning formats
· Consult regarding specialized material and/or equipment adaptations to maximize visual functioning and learning
· Consult regarding the development of child literacy programs and formats (Braille, large print, tape)
· Provide suggestions for adapting educational programs to facilitate inclusion
G. The Consultant for the Visually Impaired can liaise with with a qualified Orientation and Mobility Instructor who will:
· Assess orientation and mobility skills as they relate to the child’s environment: classroom, school, and community
· Provide program suggestions and recommendations to school personnel and family to enhance the child’s level of skill in orientation and mobility
· Provide information regarding use of sensory skills (functional vision, auditory, tactile, and olfactory) for orientation and mobility
· Develop child programs that teach mobility concepts: sighted guide, self-protective techniques, cane skills, and independent travel based upon the child’s needs
Completed By: / Parent(s) Professional Date ) (dd/mm /yyyy
RCSD Request for Consultation – Appendix B
Updated – August 15, 2015 2
Appendix C - Physiotherapy
Alberta Health Care number:A. The child has difficulty with:
Balancing (i.e., on apparatus, crowded hallway, hopscotch, walking, standing still)
Keeping straight posture when sitting or standing
Participating in games that involve running, fast changes of direction, jumping and hopping
Recognizing his/her own body parts and left from right
Throwing and catching a ball and target games
Playing on playground equipment (i.e. slide, swing, jungle gym, balance beam, etc.)
Muscle strength or endurance
Coordination in comparison to peers
Physical activities
Movements appear awkward or clumsy. Describe:
Physical development. Explain:
Needs equipment for mobility. Explain:
B. Reason for request:
C. Child/youth strengths and interests:
`D. What strategies have been tried? What strategies were effective?
E. Additional Information:
F. A Physiotherapist can help with physical function.
· Provide support regarding physical management and safety
· Assess child's motor development (strength, flexibility, posture, balance, spatial awareness, coordination and motor planning), and provide specific programs and strategies to maximize physical functioning in the school setting
· Provide support for adapting educational programs to facilitate inclusion (including physical education)
· Facilitate use of adaptive equipment and technology to maximize the child's physical function and to support access
· Provide consultation with respect to accessibility, the child's mobility within the school setting and relevant safety issues
· Facilitate interactive play skills through gross motor activities
· Provide the Physical Education teacher with further strategies to work with the child
· Provide the Physical Education teacher with game and activity suggestions for a wide range of physical abilities
Completed By: / Parent(s) Professional Date ) (dd/mm/yyyy
RCSD Request for Consultation – Appendix C
4