Pre-Referral Intervention/Information Form



Monteviedeo Area Special Education Cooperative | |       |School | |Pre-Referral Intervention/Information Form

(When general education interventions have not resulted in sufficient change, this form along with required blue intervention sheets serves as the referral to the Child Study Team.)

(Parental referral does not eliminate necessity for interventions)

|Date |       |MARSS ID# |       |

|Student' Name |       |Grade |       |DOB |       |

|Student's Primary |       |

|Language(s) | |

|Ethnic Background |       |Home Language(s) |       |

|Classroom Teacher(s) |       |

|Parents Name & Phone # |       |

I. List of students strengths and interests

|      |

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|AREAS OF CONCERN (Prioritize each concern with a 1, 2, 3, etc) | | |

|       |Ability | | |       |

|       |Attitude/Motivation | |       |Reading |

|       |

| |

| |

| |

| |

III. SCHOOL INFORMATION

A. CURRENT ACADEMIC INFORMATION

1. Current classroom grades

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|2 |Reading: |      | |      | |      |

| | |Below Grade Level | |At grade level | |Above Grade Level |

|3 |Math: |      | |      | |      |

| | |Below Grade Level | |At grade level | |Above Grade Level |

|4 |Writing Skills: |      | |      | |      |

| | |Below Grade Level | |At grade level | |Above Grade Level |

|5 |Group Achievemnet Scores: |

|7 |Other: |

B. Previous School History

|1 |Has student attended other schools? | |  |Yes | |  |

| |Where? |       | |When? |       |

| |Where? |       | |When? |       |

| | | | | |  |

| | | | | |  |

| | | | | |  |

| | | | | |  |

| | | | | |  |

|2 |Has student been retained? |

| | |

| | |

|3 |Previous referral for special | |

| |education? | |

|4 |Has student received any |  |Yes | |  |

| |special education services? | | | | |

| |Which services? |       | |When? |       |

|5 |Are there any reports in the areas below: |

| | |

| | |

IV. PARENT/GUARDIAN INFORMATION

|1 |When was the concern discussed with parents/guardians? |       |

|2 |By Whom? |       |

|3 |Do they Share your concern? |

| | |

| | |

| | |

V. INTERVENTION PLANS TRIED TO REMEDIATE PROBLEM AREA/S

|A. |Consultation with various members of professional staff (indicate consultation date) |

| |       |Chemical Awareness Counselor | |       |Police Liaison |

| |       |ELL Teacher | |       |Previous Teacher |

| |       |Ed. Speech-Language Pathologist | |       |Principal |

| |       |Health Service Specialist | |       |School Counselor |

| |       |Home/School Liaison | |       |School Psychologist |

| |       |Intervention Specialist | |       |School Social Worker |

| |       |Occupational Therapist | |       |Special Education Teacher |

| |       |Phy. Ed Teacher | |       |Title 1 Teacher/Para |

| |       |Other teachers at grade level | |       |Mental Health Agency |

| |       |Family Service Agency | |       |Probation Officer |

|B. |Accommodations Tried | |

| |1 |Behavior Accommodations Tried | |

| |  |One-to-One processing | |

| |  |Cue Learner (pink post-its) | |

| |  |Allow Movement | |

| |  |Ignore inappropriate behavior | |

| |  |Praise appropriate behaviors immediately | |

| |  |Use role models (peer mentor) | |

| |  |Review rules and expectations | |

| | |  |Other |       |

| |2 |Academic Accommodations Tried |

| |  |Preferential Seating |

| |  |Notes Home |

| |  |Title One |

| |  |Read test to student |

| |  |Shorten assignments |

| |  |One-on One/small group |

| |  |Allow extra time to complete assignments |

| |  |Simplify directions |

| |  |Pair with another learner |

| | |  |Other |       |

|C. |Intervention #1 |

|List pertinent health diagnosis/information |       |

|State any previous and/or additional medical information (diet restrictions, health restrictions, hospitalizations). |

|      |

| |

| |

|Date Completed |       | | |

(Signature of School Health Specialist)

VI. Referral

|Is a referral to the Child Study Team recommended? |

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|      |

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| |

|Date sent to Child Study for referral |       |

|Montevideo Area Special Education Cooperative | |Intervention #: |      |

| |Date: | |      |

| |Behavior | |Academic |

| |(Circle One) |

| | |

PRE-REFERRAL STUDENT INTERVENTION PLAN

Two planned, implemented, and evaluated interventions are required by State and Federal regulations prior to a Child Study Team referral for academic and/or behavior concerns. This form must be used to document each of the interventions unless the building has approved waiver from the Director of Special Education.

|      | |      | |      | |      |

|Student | |Grade | |School | |Teacher |

| | | | | | | |

|Student concerns discussed with Principal | |      | |Student concerns discussed with Parent | |      |

| | |Date | | | |Date |

|This intervention was planned with |       |

CONCERNED/DESIRED OUTCOME/GOAL (Be very specific)

|      |

| |

| |

SPECIFIC INTERVENTION PLAN

|      |

| |

| |

SPECIFIC CRITERIA FOR SUCCESS

|      |

| |

| |

METHOD OF DATA COLLECTION

|      |

| |

|This plan will be in effect from |       |to |       |

| |start date | |review date |

|Review date: |  |

PRE-REFERRAL STUDENT INTERVENTION PLAN REVIEW

SPECIFIC RESULTS (attach supporting date)

| |

| |

| |

|(Check | |

|One) | |

|  |INITIATE ANOTHER INTERVENTION |

|  |INITIATE REFERRAL TO CHILD STUDY TEAM |

|cc: |Cum File | |

| |Other |       |

|Montevideo Area Special Education Cooperative | |Intervention #: |      |

| |Date: | |      |

| |Behavior | |Academic |

| |(Circle One) |

| | |

PRE-REFERRAL STUDENT INTERVENTION PLAN

Two planned, implemented, and evaluated interventions are required by State and Federal regulations prior to a Child Study Team referral for academic and/or behavior concerns. This form must be used to document each of the interventions unless the building has approved waiver from the Director of Special Education.

|      | |      | |      | |      |

|Student | |Grade | |School | |Teacher |

| | | | | | | |

|Student concerns discussed with Principal | |      | |Student concerns discussed with Parent | |      |

| | |Date | | | |Date |

|This intervention was planned with |       |

CONCERNED/DESIRED OUTCOME/GOAL (Be very specific)

|      |

| |

| |

SPECIFIC INTERVENTION PLAN

|      |

| |

| |

SPECIFIC CRITERIA FOR SUCCESS

|      |

| |

| |

METHOD OF DATA COLLECTION

|      |

| |

|This plan will be in effect from |       |to |       |

| |start date | |review date |

|Review date: |  |

PRE-REFERRAL STUDENT INTERVENTION PLAN REVIEW

SPECIFIC RESULTS (attach supporting date)

| |

| |

| |

|(Check | |

|One) | |

|  |INITIATE ANOTHER INTERVENTION |

|  |INITIATE REFERRAL TO CHILD STUDY TEAM |

|cc: |Cum File | |

| |Other |       |

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