National Association of School Psychologists (NASP)



SAMPLEStudent Name: John Miller School: Tiny Town Elementary SchoolGrade: 5thRelated IEP Goals: 1. John will self-identify debilitating anxiety producing situations (e.g., interrupt ability to complete and follow-through with tasks, contribute to extreme feelings of helplessness, stimulate physical and emotional withdrawal from others, etc.) at least 80% of the time and keep a journal of these experiences and what he observed as they occur. 2. John will respond to self-identified debilitating anxiety producing situations by initiating the use of anxiety reduction strategies (e.g., relaxation and breathing exercises, visualization) without adult support 80% of the time. DateGoal Addressed?Who Is Provider?Service Delivered?Service Duration (min)AccommodationsModificationsStudent Response/ProgressOther NotesExample:3/20/20Increase self-identify anxiety attacks and initiate use of anxiety reduction strategies. Jane Smith, School Psychologist1:1 Counseling. Reviewed student use of anxiety red tech over last 3 days. Practiced strategies for anxiety reduction.Consultation with parent.20 minutes10 minutesTeletherapy. Used Zoom conferencing for counseling session and follow up phone call with mother.Student journal recorded five debilitating anxiety attacks in last 3 days. 3/5 attacks student self-initiated breathing exercises and relief was experienced. Parent assisted with two. John’s mother confirmed John’s accounting. Family working to limit John’s exposure to TV news reports about the pandemic.Student Name:_________________________________School: _____________________________Grade: __________________Related IEP Goals: DateGoal Addressed?Who Is Provider?Service Delivered?Service Duration (min)AccommodationsModificationsStudent Response/ProgressOther Notes ................
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