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| |Form 210-5 |

| |School Level Intervention Process Pre-Referral Checklist |

|[pic] |Insert School Name, |Reference |AP 210 Services for Students With Diverse Needs |

| |Address, Town, Sask., Postal Code | | |

| |Phone: (Number) Fax: (Number) | | |

| |email address if applicable | | |

| | |Revised |September 14, 2018 |

| | |Level |School |

| | |Submit to |Student Support Teacher |

| | |When |As required |

(Adapted from: “Guidelines for the Practice of Professional Psychology in Schools in Saskatchewan”)

When teachers have concerns about a student’s lack of progress, there are many things they can do to support the student. It is important to intervene as soon as the teacher recognizes that a student is falling behind. Please refer to the following suggested guidelines to develop a classroom intervention plan prior to referring the child for a comprehensive student services assessment.

|Date | | | |

| | | |Review cumulative file for information. |

| | | |Collect data on student through informal assessment, observation, and discussion with previous teachers. |

| | | |Consider the student’s learner profile. |

| | | | |

| | | |Ensure vision, hearing, and medical assessments are up to date. |

| | | |Document observations of students. |

| | | |Identify areas of strength and weakness. |

| | | |Discuss concerns with the Triad (Administrator, PeBL Mentor, and Student Support Teacher) and/or |

| | | |parents/guardians. |

| | | | |

| | | |Implement intervention strategies in area(s) of need. |

| | | |Monitor progress. |

| | | |If the student continues to struggle, access the in-school Student Support Team for further strategies. |

| | | | |

| | | |Monitor progress. |

| | | |If the student continues to struggle, contact the Student Support Consultant to discuss specific areas of |

| | | |difficulty. A recommendation to consult with the Student Support Services Personnel may be suggested. |

| | | | |

| | | |Student Support Services personnel will provide additional intervention strategies based on the available |

| | | |data and/or may recommend the implementation of further informal assessment in addition to intervention |

| | | |strategies. |

| | | | |

| | | |Implement suggested intervention plan. |

| | | | |

| | | |Monitor progress. |

| | | | |

| | | |If the student continues to struggle, refer the students for a complete Student Support Services assessment. |

| | | | |

| | | |

|Teacher’s Signature | |Date |

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