Flagstaff Unified School District



SPED Therapist Counseling Referral Form for Secondary Students Identified in Special EducationStudent:DOB: FORMTEXT ?????Grade: FORMTEXT ?????Referred by: FORMTEXT ?????Instructions: Check off ALL areas of concernReason for Referral:Current School Functioning and Desire for Assistance: FORMCHECKBOX Difficulty making a transition FORMCHECKBOX Social Problems FORMCHECKBOX Behavioral Problems FORMCHECKBOX Academic ProblemsAbsent from School: FORMCHECKBOX Seldom FORMCHECKBOX 1x/month FORMCHECKBOX 2-3 /month FORMCHECKBOX 4+ /monthAbsent from Class: FORMTEXT ????? which class FORMTEXT ????? Number of absences/month FORMTEXT ?????Overall Academic Performance FORMCHECKBOX Poor Grades FORMCHECKBOX Change in Performance FORMCHECKBOX Low MotivationRTC- Administration referrals in the current school year: FORMTEXT ????? how many FORMTEXT ????? Days Suspended in the current school year FORMTEXT ?????Past school Year FORMTEXT ?????Has Family or Student asked for Information about School services FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIs outside community counseling involved: FORMCHECKBOX Yes Where: FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX UnknownIs there a FBA/BIP in place and used FORMCHECKBOX Yes FORMCHECKBOX NoMajor Psychosocial or Mental Health Concerns: Check all that you are aware of… FORMCHECKBOX Drug/alcohol abuse FORMCHECKBOX Depression FORMCHECKBOX Grief FORMCHECKBOX Crying/tearfulness FORMCHECKBOX Dropout prevention FORMCHECKBOX Gang involvement FORMCHECKBOX Pregnancy support FORMCHECKBOX Lethargic/sleeping in class FORMCHECKBOX Eating problems FORMCHECKBOX Physical/sexual abuse FORMCHECKBOX Neglect FORMCHECKBOX Excessive tardiness FORMCHECKBOX Reactions to chronic illness FORMCHECKBOX Self Esteem issues FORMCHECKBOX Family relationship problems FORMCHECKBOX Slipping grades FORMCHECKBOX Frequent Somatic complaints (Headaches, Stomach Aches, etc.) FORMCHECKBOX Verbally threatening FORMCHECKBOX Parent divorce or separation FORMCHECKBOX Sudden change of mood or behavior FORMCHECKBOX Isolating from peers FORMCHECKBOX Physical aggressive FORMCHECKBOX Out of home placement FORMCHECKBOX Excessive absenteeism FORMCHECKBOX Recent withdrawal from friends FORMCHECKBOX Disruptive behaviors FORMCHECKBOX Recent Homelessness FORMCHECKBOX Deteriorated hygiene FORMCHECKBOX Excluded by peers/lacks significant friends FORMCHECKBOX Inappropriate language/gestures FORMCHECKBOX Death of family or friend FORMCHECKBOX Failure or refusal to complete tasks FORMCHECKBOX Anxiety/Phobia FORMCHECKBOX Inappropriate sexual behaviors FORMCHECKBOX Attention seeking behaviors FORMCHECKBOX Excessive dislike of school FORMCHECKBOX Suicide ideation FORMCHECKBOX Current FORMCHECKBOX Past month FORMCHECKBOX Past 6 months FORMCHECKBOX Has been hospitalized in past for Suicide ideation FORMCHECKBOX Self-harm FORMCHECKBOX Legal Problems FORMCHECKBOX Failure to complete or turn in homework FORMCHECKBOX Easily distracted FORMCHECKBOX Destruction of property FORMCHECKBOX Argumentative behaviors FORMCHECKBOX Anger outbursts FORMCHECKBOX Disrespectful behaviors FORMCHECKBOX Refusal to comply with rules FORMCHECKBOX Refusal to comply with requests FORMCHECKBOX Easily distracted FORMCHECKBOX Other: FORMTEXT ?????Describe in your own words concerns the child has been exhibiting and length of time it has impacted school performance: FORMTEXT ?????Other staff who have concerns that Therapist can contact: FORMTEXT ?????ALL FUSD Employees are Mandated to Report Suspected Child Abuse: 1-888-767-2445***Counseling is a related service, not a standalone service. Student must be identified as having a disability that interferes with education under the criteria of IDEA. Eligibility is not based on specific test scores or discrepancies, rather on whether the unique expertise of the therapist is required for the student’s educational participation. Medical diagnosis itself does not determine eligibility under IDEA. The disability must “Adversely affect the child’s educational performance”.*** ................
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