Student Assistance Team Referral

LOGAN COUNTY

STUDENT ASSISTANCE TEAM REFERRAL

This form must be completed by the person making the referral to SAT

and returned to the SAT Coordinator.

School: ______WVEIS: ______Date:______

Student Name: ______D.O.B______

Current Grade: ______Grade(s) Retained ______Teacher: ______

Parent(s) or Guardian(s):

Mailing Address: ______City: ______, WV Zip: ______

Home Phone#: ______Work Phone#: ______Cell Phone:______

Mark only the areas of concern below that significantly affect the student’s classroom performance.

____Academic Concerns Please explain:

____Medical/Health Concerns Please explain:

____Behavior Concerns Please explain:

____Emotional/Social Concerns Please explain:

Other Concerns:

Attendance

Hyperactivity

Impulsivity

Short Attention Span

Language Development

Organizational Skills

Low Self-Esteem

Memory Skills

Following Directions

Gross Motor Skills

Fine Motor Skills

Motivation

Withdrawn

Repeated movements or vocalizations

Other:______

Tier 1 Interventions and/or Accommodations

Check any that have been used prior to SAT referral:

Rephrasing; Previewing

Graphic Organizers

Visual/Verbal Cues

Peer Tutoring

Cooperative Learning

Frequent Praise

Small Group Instruction

Memory Drills

Computer Assisted Instruction

Manipulatives for Math

Title 1 Reading

Guided Practice/Extra Practice

Re-teaching of Concepts

Modeling

Increase Wait Time for Questions

Priority Seating

Extended time

Shortened assignments

Other:______

Attachments

If student is having academic difficulties, please attach a sample of the student’s work, assessments and/or progress monitoring data that reflects your concerns.
If student has a medical concern, please attach any known relevant information or history.
If there is a behavioral concern, please attach any disciplinary action taken.

Parent Involvement

Describe parent/guardian contact prior to the current referral to SAT. Include dates of meetings if applicable.

Signature of Person Completing FormTitle/PositionDate

Logan County Schools

Notice of and Invitation to SAT Meeting

Date of Notice/Invitation:______

Dear Parent,

The Student Assistance Team (SAT) has been asked to review ______’s individual needs to determine if additional supports are necessary. The SAT reviews educational/behavioral needs and progress of any student who demonstrates a need for supplemental classroom support. The team will review existing data and, as needed, conduct observations and/or do additional screening.

We need your input and participation in working with us to meet your child’s needs. We invite you to attend the SAT meeting to contribute your valuable insight. Please sign the bottom of this form and return to me to indicate if you would like to attend. If you have any questions or need to arrange another time to meet, please contact me at ______.

Meeting Date:______

Time: ______

Location:______

Sincerely,

______, SAT Coordinator

Parent/Guardian,

Please check all that apply:

I give my permission for additional screening, if needed.

I plan to attend the SAT meeting.

I do not want to attend the SAT meeting. Please send me a copy of the summary of the meeting.

I need to reschedule the meeting to another date.

Parent/Guardian Signature: Date:

Logan County Schools

Student Assistance Team Referral

Meeting 1

Student: ______WVEIS: ______Date:______

Referred by: ____Teacher____Parent_____Other:______

BACKGROUND INFORMATION:

HEALTH

Vision

_____Poor_____Corrected with Assistance_____Good/Excellent

Hearing

_____Poor_____Corrected with Assistance_____Good/Excellent

Speech/Language

_____Normal______Unintelligible_____Articulation Errors

Physical Health Concerns

_____Fragile ______Chronic Illness Please specify:

_____Good/Excellent

Medications

Please list any current medications.

Serious Accidents/Head Injuries

____No history_____Yes Please specify:

Psychiatric/Psychological Treatment

____No history_____Yes Please specify dates and facilities:

ACADEMIC PROGRESS TOWARDS GRADE LEVEL STANDARDS

Reading

_____Significantly Below _____Below_____At Level_____Above Level

Math

_____Significantly Below _____Below_____At Level_____Above Level

Written Language

_____Significantly Below _____Below_____At Level_____Above Level

ATTENDANCE

_____Good/Excellent (Less than 10 absences)_____Poor (More than 10) _____Habitually Truant (More than 20)

SAT Intervention Plan

1)Area of Concern:

Summary of Most Recent Progress Monitoring and/or Screening Results:

Measurable Goal:

Intervention Plan / Person responsible?
Write a brief description of the intervention(s) to be used with student. / Frequency/Duration (Minimum of 9 Weeks)
(How often? How much? How long?)
Progress Monitoring(CBM; DIBELS; Behavior Forms; etc.) :
Type of data collected?
How often will progress monitoring data be collected and charted?
By whom?

2)Area of Concern:

Summary of Most Recent Progress Monitoring and/or Screening Results

Measurable Goal:

The students’ parents were notified about the following:

The state’s policy regarding the amount and nature of student performance data that would be collected and the general education services that would be provided; strategies for increasing the student’s rate of learning; results of repeated assessments of student progress and the parents right to request an evaluation at any time throughout the process.

Date of Parent Notification: Parent’s Initial:

Follow up:

A follow up SAT meeting will be scheduled inweeks at School.

We have reviewed and agreed to this plan (Must have at least 3 team members):

SAT Coordinator

Principal

Teacher

Title 1

Parent/Guardian

School Psychologist

Other

Logan County Schools

Notice of and Invitation to SAT Meeting

Date of Notice/Invitation:______

Dear Parent,

Meeting Date:______

Time: ______

Location:______

Sincerely,

______, SAT Coordinator

Parent/Guardian,

Please check all that apply:

I give my permission for additional screening, if needed.

I plan to attend the SAT meeting.

I do not want to attend the SAT meeting. Please send me a copy of the summary of the meeting.

I need to reschedule the meeting to another date.

Parent/Guardian Signature: Date:

Logan County Schools

Student Assistance Team Referral

Meeting 2

Student: ______WVEIS: ______Date:______

The purpose of this follow-up meeting is to review the progress of the interventions developed by the SAT.

Fidelity Statement:

I verify that the plan written in Meeting 1 was conducted as described.

Signature of Administrator or Designee:

Goal from Previous Meeting

1)Previous Goal:

Summary of Progress (attach any documentation to support that the plan was implemented and progress monitoring data/graphs/charts):

Current Level of Performance:

New/Updated Goal:

2)Previous Goal:

Summary of Progress (attach any documentation to support that the plan was implemented and progress monitoring data/graphs/charts):

Current Level of Performance:

New/ Updated Goal:

Based on discussion and evaluation of data, the recommendation is:

(Check all that apply)

Continue present interventions/services with no changes. Review by:

Change present interventions/services with new ones as shown below. Review again by:

Phase out present interventions by:

Refer for speech/hearing/vision screening immediately

Refer to 504 Coordinator to develop a 504 Plan.

New Intervention / Person responsible?
Write a brief description of the intervention(s) to be used with student. / Frequency/Duration (Minimum of 9 Weeks)
(How often? How much? How long?)
Progress Monitoring(CBM; DIBELS; Behavior Forms; etc.):
Type of data collected?
How often will progress monitoring data be collected and charted?
By whom?
New Intervention / Person responsible?
Write a brief description of the intervention(s) to be used with student. / Frequency/Duration (Minimum of 9 Weeks)
(How often? How much? How long?)
Progress Monitoring(CBM; DIBELS; Behavior Forms; etc.):
Type of data collected?
How often will progress monitoring data be collected and charted?
By whom?

Follow up:

A follow up SAT meeting will be scheduled inweeks at School.

We have reviewed and agreed to this plan:

SAT Coordinator

Principal

Teacher

Title 1

Parent/Guardian

School Psychologist

Other

Other:

Logan County Schools

Notice of and Invitation to SAT Meeting

Date of Notice/Invitation:______

Dear Parent,

Meeting Date:______

Time: ______

Location:______

Sincerely,

______, SAT Coordinator

Parent/Guardian,

Please check all that apply:

I give my permission for additional screening, if needed.

I plan to attend the SAT meeting.

I do not want to attend the SAT meeting. Please send me a copy of the summary of the meeting.

I need to reschedule the meeting to another date.

Parent/Guardian Signature: Date:

Logan County Schools

Student Assistance Team Referral

Meeting 3

Student: ______WVEIS: ______Date:______

The purpose of this follow-up meeting is to review the progress of the interventions developed by the SAT.

Fidelity Statement:

I verify that the plan written in Meeting 2 was conducted as described.

Signature of Administrator or Designee:

Goal from Previous Meeting

1)Previous Goal:

Summary of Progress (attach any documentation to support that the plan was implemented and progress monitoring data/graphs/charts):

Current Level of Performance:

New/Updated Goal:

2)Previous Goal:

Summary of Progress (attach any documentation to support that the plan was implemented and progress monitoring data/graphs/charts):

Current Level of Performance:

New/ Updated Goal:

Based on discussion and evaluation of data, the recommendation is:

(Check all that apply)

Continue present interventions/services with no changes. Review by:

Change present interventions/services with new ones as shown below. Review again by:

Phase out present interventions by:

Refer for speech/hearing/vision screening immediately

Refer to 504 Coordinator to develop a 504 Plan.

Growth rate is flat or declining in comparison of peers. Rate is such that specially designed instruction may be necessary. Refer for a psycho-educational evaluation.

New Intervention / Person responsible?
Write a brief description of the intervention(s) to be used with student. / Frequency/Duration (Minimum of 9 Weeks)
(How often? How much? How long?)
Progress Monitoring(CBM; DIBELS; Behavior forms; etc.):
Type of data collected?
How often will progress monitoring data be collected and charted?
By whom?
New Intervention / Person responsible?
Write a brief description of the intervention(s) to be used with student. / Frequency/Duration (Minimum of 9 Weeks)
(How often? How much? How long?)
Progress Monitoring(CBM; DIBELS; Behavior forms; etc.):
Type of data collected?
How often will progress monitoring data be collected and charted?
By whom?

Follow up:

A follow up SAT meeting will be scheduled inweeks at School.

We have reviewed and agreed to this plan:

SAT Coordinator

Principal

Teacher

Title 1

Parent/Guardian

School Psychologist

Other

Logan County Schools

Notice of and Invitation to SAT Meeting

Date of Notice/Invitation:______

Dear Parent,

The Student Assistance Team (SAT) has been asked to review ______individual needs to determine if additional supports are necessary. The SAT reviews educational/behavioral needs and progress of any student who demonstrates a need for supplemental classroom support. The team will review existing data and, as needed, conduct observations and/or do additional screening.

Meeting Date:______

Time: ______

Location:______

Sincerely,

______, SAT Coordinator

Parent/Guardian,

Please check all that apply:

I give my permission for additional screening, if needed.

I plan to attend the SAT meeting.

I do not want to attend the SAT meeting. Please send me a copy of the summary of the meeting.

I need to reschedule the meeting to another date.

Parent/Guardian Signature: Date:

Logan County Schools

Student Assistance Team Referral

Meeting ___

Student: ______WVEIS: ______Date:______

The purpose of this follow-up meeting is to review the progress of the interventions developed by the SAT.

Fidelity Statement:

I verify that the plan written in Meeting ___ was conducted as described.

Signature of Administrator or Designee:

Goal from Previous Meeting

1)Previous Goal:

Summary of Progress (attach any documentation to support that the plan was implemented and progress monitoring data/graphs/charts):

Current Level of Performance:

New/Updated Goal:

2)Previous Goal:

Summary of Progress (attach any documentation to support that the plan was implemented and progress monitoring data/graphs/charts):

Current Level of Performance:

New/ Updated Goal:

Based on discussion and evaluation of data, the recommendation is:

(Check all that apply)

Continue present interventions/services with no changes. Review by:

Change present interventions/services with new ones as shown below. Review again by:

Phase out present interventions by:

Refer for speech/hearing/vision screening immediately

Refer to 504 Coordinator to develop a 504 Plan.

Growth rate is flat or declining in comparison of peers. Rate is such that specially designed instruction may be necessary. Refer for a psycho-educational evaluation.

New Intervention / Person responsible?
Write a brief description of the intervention(s) to be used with student. / Frequency/Duration (Minimum of 9 Weeks)
(How often? How much? How long?)
Progress Monitoring(CBM; DIBELS; Behavior forms; etc.):
Type of data collected?
How often will progress monitoring data be collected and charted?
By whom?
New Intervention / Person responsible?
Write a brief description of the intervention(s) to be used with student. / Frequency/Duration (Minimum of 9 Weeks)
(How often? How much? How long?)
Progress Monitoring(CBM; DIBELS; Behavior forms; etc.):
Type of data collected?
How often will progress monitoring data be collected and charted?
By whom?

Follow up:

A follow up SAT meeting will be scheduled inweeks at School.

We have reviewed and agreed to this plan:

SAT Coordinator

Principal

Teacher

Title 1

Parent/Guardian

School Psychologist

Other