REFERRAL

 

Name:____________________________________D.O.B.________Sex:______Grade:_______

I.D. Number_______________________________   School/District:______________________

Parent/Guardian:____________________________  Teacher:____________________________

Address:___________________________________  Primary Language:___________________

__________________________________________  Home Phone:________________________

Student Represented by:____Parent  ____Guardian  ____Self  ____Surrogate

Referral Source:____________________________________________ Grade:______________

                                                    (name)                                                                 (title)

 

I.                                                                               MAJOR AREA(S) OF CONCERN SUSPECTED ADVERSELY AFFECT(S) EDUCATIONAL PERFORMANCE:  Check each reason for referring this student:

 

___Physical Functioning            ___Communication Functioning            ___Cognitive Functioning

___Social Competence ___Academic Performance                   ___Vocational Functioning

___Recreation & Leisure          ___Other:___________________

 

Explain the item(s) checked above; including past and present performance, results of recent testing, and any medical information related to the referral concern.  Attach additional sheet if needed.

_____________________________________________________________________________

_____________________________________________________________________________

 

II.                                                                            CURRENT STATUS IN RELATION TO SIMILAR AGE PEERS:

Indicate (+) strength; (-) weakness.  If age appropriate, leave blank:

 

PHYSICAL FUNCTIONING                             COMMUNICATION FUNCTIONING

___achieved developmental milestones                                  ___communicates needs

___is aware of/attends to appearance                                     ___communicates likes/dislikes

___uses movement to express feelings                                   ___expresses emotions/feelings

___maintains healthy life-style                                                 ___responds to questions

___performs gross motor skill effectively                               ___Communicates ideas fluently

___performs fine motor skills effectively                                 ___ uses gestures in an effort to communicate

___recognizes/responds to dangers                                        ___relates personal information

___normal vision                                                                         ___maintains eye contact

___normal hearing                                                                       ___speech is easily understood

___self-care skills                                                                        ___uses age-appropriate vocabulary

___general health                                                                        ___organizes ideas

___other (Specify)_____________________                      ___other (Specify)_______________________

 

COGNITIVE FUNCTIONING                          SOCIAL COMPETENCE:

___understands developmental concepts                                              (adaptive behavior and social skills)

___uses creative skills to construct ideas/products             ___demonstrates emotional/mental wellness

___understands number concepts                                           ___demonstrates self-control

___predicts events/results                                                        ___uses positive social judgment

___interprets data to make decisions                                       ___uses effective interpersonal skills

___understands spatial concepts                                             ___uses productive team membership skills

___demonstrates sense of time                                                 ___demonstrates positive self-concept

___analyzes information to solve problems                            ___demonstrates self-help skills

___compares/contrasts objects, events                                  ___exhibits consistent moods

___compares/contrasts ideas                                                    ___uses positive problem solving strategies

___uses critical thinking skills in various situations             ___considers alternative perspectives

___understands spatial and dimensional concepts               ___effectively transitions between activities

___Other (Specify)_______________________                ___Other (Specify)______________________

REFERRAL (Cont.)

 

Name____________________________________________________

 

ACADEMIC PERFORMANCE:                       VOCATIONAL FUNCTIONING:

___organizes information                                                           ___demonstrates independent work habits

___applies math concepts to solve problems                         ___communicates with supervisors

___understands/uses math procedures                                  ___uses technology effectively

___understands measurement concepts                                 ___organizes materials/belongings

___demonstrates effective consumer skills                            ___seeks assistance as needed

___understands ideas through listening                                 ___uses school/work tools effectively

___reads printed materials for meaning                                   ___cooperates with peers/coworkers

___communicates ideas through writing                                 ___identifies preferences/interests

___uses research tools effectively                                           ___recognizes personal limitations

___ uses technology to gather/organize information            ___sets realistic vocational goals

___ produces/completes school work                                     ___Other (Specify)____________________

___ communicates ideas through visual arts                          ____________________________________

___ uses models/scale/manipulatives to illustrate ideas      ____________________________________

___Other (Specify)___________________________       _____________________________________

 

RECREATIONAL/LEISURE FUNCTIONING:

___interacts with sage-age peers                                             ___demonstrates good sportsmanship

___uses free time wisely                                                            ___chooses age-appropriate activites

                                                                                                        ___participates in community recreation

 

III RECORD REVIEW

 

Attendance

Year & Grade

                  /

                       /

                    /

                   /

                  /

Absence

 

 

 

 

 

Enrollment

 

 

 

 

 

Tardy

 

 

 

 

 

 

Hearing Screen                                                           Vision Screen                                      Communication Screen

Date:________                                                            Date:________                                    Date:________

____Pass                                                                      Near                        Far                          ____Pass

____Fail                                                                        ____Pass              ____Pass              ____Fail

                                                                                        ____Fail                                ____Fail

 

ENVIRONMENTAL, FAMILY, CULTURAL FACTORS: (check all which are documented)

___excessive home responsibilities                                         ___abuse and/or neglect

___homelessness(past or present)                                           ___alcohol/drug abuse by family members

___moves frequently                                                                  ___alcohol/drug abuse by student

___student employed outside the home                                 ___recent trauma (physical or emotional)

___limited experiential background                                          ___significantly different cultural experience

 

IV ATTACHMENTS

A summary of interventions that have been provided and proven ineffective for any area of concern that adversely affects educational performance is attached.

 

Submitted to ARC Chairperson:_______________________________________  Date___________________

                                                                           Signature of Chairperson

 

        This referral, as reviewed by the Admissions and Release Committee, indicates a suspected disability and there is a need for a full and individual evaluation.

        This referral, as reviewed by the Admission and Release Committee, does not include sufficient information to indicate a suspected disability or the need for an individual evaluation.

        This referral, as reviewed by the Admission Release Committee, does not indicate suspected disability and there is not a need for individual evaluation.