Unalaska City School District

Student Assistance Team Referral Form

Name of Student:__________________________ Date of Referral (mm/dd/yyyy): ________________

Age: _________ Birthdate (mm/dd/yyyy): _______________ Gender: ___________________

Referred by: _______________________________________ Grade: _________________

School: ______________ Teacher: ______________________________

Parent/Guardian/Surrogate: _________________ Work Phone: __________________________

Address: ______________________________ Home Phone: __________________________

(P.O. Box, Street address)

_____________________________________

(City, State, Zip)

Reason for Referral:

1. Fine Motor Skills 8. Social/Emotional/Behavioral

2. Gross Motor Skills 9. Reading

3. Medical 10. Writing

4. Hearing 11. Math

5. Vision 12. Pre-academic School Readiness

6. Speech 13. Other (please describe in attachment)

7. Language

Please explain the reason for the referral in as much detail as possible. Attach if needed:

__________________________________________________________

Summary of Existing Information:

Prior Special Education Referral Date(s): ______________________

Prior Evaluations (may include):

Psychological (mm/dd/yyyy): ___________________ Educational (mm/dd/yyyy): __________________

Speech/Language (mm/dd/yyyy): _____________________ Physical/Medical (mm/dd/yyyy): _________

Days absent: _________________ / __________________

(This year) (Last year)

Days suspended: ______________/ ______________ Grades repeated: ____________

(This year) (Last year)

Linguistic Background:

Primary Language of Student: ___________________ Primary Language of Home: ________________

Screening Information: Vision: _________________ Hearing: _______________________

(mm/dd/yyyy) (mm/dd/yyyy)

Medications: _____________________________________________________

Attachments:

Report Card Current Work Samples Developmental Profile ESL Testing

Pre-Referral Interventions Standardized Tests Student Observation Other

Name of Student: _________________________________________

Teacher Observation: Please answer the following questions using behavioral terms whenever possible.

What symptoms are the child exhibiting that is of concern at this time?

__________________________________________________________________________________

What intervention strategies have you tried that have worked?

__________________________________________________________________________________

What intervention strategies have you tried that have not seemed to work?

__________________________________________________________________________________

What are the child’s present academic levels of functioning?

__________________________________________________________________________________

Do the child’s achievement test scores (Benchmarks, CAT tests, others) or report cards indicate consistent areas

of weakness over time? Please describe.

__________________________________________________________________________________

Please describe the child’s social behavior.

__________________________________________________________________________________

Have the parents/guardian been contacted regarding this referral? If yes, please note the date and method

of contact (phone, in-person, mail, etc). If no, please explain why and list all attempts to contact the parents.

__________________________________________________________________________________

Name of Student___________________________________

Student Behavior Rating Scale

Academic Behavior:	Always	Most	Sometimes	Seldom	Never
Has trouble comprehending what is read
Uses adequate word attack skills
Loses place while reading
Slows down when reading aloud
Exhibits good sight word vocabulary
Shows adequate math computation skills
Understands word problems
Applies math skills in solving problems
Exhibits appropriate handwriting for age
Exhibits adequate spelling skills for age
Classroom Behavior:
Exhibits impulsivity
Exhibits distractibility
Gets along with peers
Follows rules of a game
Willing to reason
Conforms to boundaries and rules in class
Attends to task
Completes homework
Completes work in allotted time