SPECIAL EDUCATION ASSOCIATION OF PEORIA COUNTY
SPECIAL EDUCATION ASSOCIATION OF PEORIA COUNTY
4812 W Pfeiffer Rd., Bartonville, IL. 61607
Ph: 309-697-0880 Fax: 309-697-0884
REQUEST FOR CONSULTATION
Student: First: Mid: Last: Birth Date: Grade: Gender:
Current Program: General Education RtI Team Referral Special Education Current Eligibility/Category:
Teacher(s): Best Time to Contact Teacher:
Resident District: Serving District: School of Attendance:
School Phone #: Teacher(s) Email:
**PLEASE ATTACH STUDENT AND TEACHER DAILY SCHEDULE**
CONSULTATION REQUESTED:
| Adapted PE | OT (sensory or fine motor) |
|Autism/Behavior/Learning |PT |
|Hearing (Hearing report attached) |Social Worker |
|Home/School Liaison |Vision (Attach Form 809 & Ocular Report if available) |
CHECK AREAS OF CONCERN RELATED TO THIS REQUEST
| | | | |
| |Reading |Writing |Describe: |
| | | | |
|Learning |Math |Study Skills | |
| | | | |
| |Spelling |Work Completion | |
| | | | |
| | |Other | |
| | | | |
| |Aggression |Disruptions |Describe: |
| | | | |
| |Non-Compliance |Social Skills | |
|Social Behaviors | | | |
| |Withdrawal | | |
| | |Self-Management | |
| |Self Image | | |
| | |Communications | |
| |Attention Problems | | |
| | |Other | |
| | | | |
| |Receptive | |Describe: |
| |Language |Understanding | |
|Communication | |Non-verbal Cues | |
| |Expressive | | |
| |Language | | |
| | |Other | |
| | | | |
| |Visual Sensitivity |Coping with |Describe: |
| | |Environment | |
|Sensory |Auditory Sensitivity | | |
| | |Other | |
| |Touch Sensitivity | | |
| | | | |
| |Fine Motor |Hearing |Describe: |
| | | | |
|Physical |Gross Motor |Vision | |
| | | | |
| |General Health |Other | |
REQUEST FOR CONSULTATION
For the problems listed on the front, list the intervention strategies that have been attempted and the results:
Strategy 1:
Result 1a:
Strategy 2:
Result 2a:
Strategy 3:
Result 3a:
Previous personnel involvement:
Social Worker Counselor RtI Team SEAPCO Consultant Outside Agency
If so, who:
COMPLETE FOR BEHAVIOR CONSULTATION REQUESTS ONLY:
List Below each Behavior Problem, the Length of observance (2-3 months, 1 semester, all year, etc.), the Frequency you observed the behavior (2-3 times per day, every hour, certain time of day, etc.); and the Duration of each behavior (1-10 mins., 10-20 mins., more than 30 mins., etc):
1. Behavior Problem:
Length of Observance: Frequency: Duration:
2. Behavior Problem:
Length of Observance: Frequency: Duration:
3. 1. Behavior Problem:
Length of Observance: Frequency: Duration:
Describe or attach the behavior management system currently in place for the entire class:
Date Parent Notified:
Referring District Person Notifying Parent:
Please Print Name Signature
Signature of Referring Person __________________________________________________ Date ________________
Authorized Administrator ______________________________________________________ Date ________________
********************************************************************************************************************************
FOR OFFICE USE ONLY
Reviewed by Director _____________________________ Date ________________ Processor’s Initials ______
Personnel assigned: ________________________________
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