Referral for which service?
Student Health Outreach Services (SHOS)
Support Team for Assessment Rehabilitation and Training (START) / Date Received
Regional Educational Assessment and Consultation Services (REACH)
Psychologist
CESD Student Services Coordinator
Speech Language Pathologist (PUF only) / Student Services Signature
STUDENT’S Legal Name: / Birthdate: / Grade: / Gender:
D/M/Y
Name of individual completing form: / Date completed:
Alberta Education I.D. #: / Other:
PARENT(S): / Legal Guardian(s):
(if different)
Address(es): / Address(es):
E-mail: / E-mail:
Home Phone: / Work Phone: / Cell Phone:
SCHOOL: / Address:
School Phone: / Principal:
School Fax: / Teacher:
E-mail: / E.A.:
Attendance schedule: (eg. T/Th am / Liaison:
DIAGNOSES:
Conditions / Date of Diagnoses / Who Diagnosed?
Student Funding Code: / PUF / Yes / No
Additional medical information:

Reason for Referral (THIS SECTION MUST BE COMPLETED):

Request for service:

Assistive Technology / Occupational Therapy
Behaviour Assessment / Orientation and Mobility (for visually impaired)
Behaviour Consultation / Physical Therapy
Programming Consultation / Educational Audiology (Audiogram must be attached)
Psycho-educational Assessment / Hearing Consultant (Audiogram must be attached)
Nursing / Vision (Ophthalmology repoert must be attached)
1. Please list all services that your student is currently or has accessed within the last two years within the school and/or community. (e.g. FSW, Private Counsellors, Chidlren’s Mental Health, Speech, Resource, Early Literacy, etc.)
2. Please list your student’s strengths and interests
3. Please describe your student’s emotional/social development (e.g. classroom/school behaviour, relations with peers, attitudes, relations with teachers, etc.
4. Is school attendance a concern? / School lates? / Grades repeated? / Accelerated?
5. What are Level B assessment results (list test and standard scores)
6. Has vision been recently assessed? / Date:
7. Has hearing been recently assessed? / Date:
8. Is your student taking medication: / Describe:
9. Please provide one or two questions you would like answered about this student and/or state your concerns

Classroom Observation Checklist

Please complete ALL sections of the following checklist. Feel free to attach a page with additional concerns or information.

Physical Therapy

  1. My student has difficulty with:

Balancing (i.e., on apparatus, crowded hallway, hopscotch, walking, standing still).

Getting his/her hands out in time to stop from falling.

Keeping tall posture when sitting or standing.

Participating in games that involve running, fast changes of direction, jumping and hopping.

Recognizing his/her own body parts and left from right.

Throwing and catching a ball and target games.

Playing on playground equipment (i.e., slide, swing, jungle gym, balance beam, etc.)

Fear of heights or movement

My student:

 Appears to have weak muscles.

 Is clumsy and awkward with movements. Describe:

______

 Appears less coordinated than classmates.

 Is particularly weak in Physical Education class.

 I am concerned about my student’s physical development. Explain:

______

 If there were one thing I wish could be physically easier for my student to do, it would be:

______

B. What strategies have been tried? Did they work or not work?

C. How can a Physical Therapist help?

Provide support to the classroom team regarding physical management and safety.

 Assess student’s motor development (strength, flexibility, posture, balance, spatial awareness, coordination and motor planning), and provide specific programs and strategies to maximize physical functioning in the school setting.

Provide support to teachers for adapting educational programs to facilitate inclusion (including physical education).

 Facilitate use of adaptive equipment and technology within the school setting to maximize the student’s physical function and to support access.

 Provide consultation with respect to school accessibility, the student’s mobility within the school setting and relevant safety issues.

 Facilitate interactive play skills through gross motor activities.

 Provide the Physical Education teacher with further strategies to work with the student.

 Provide the Physical Education teacher with game and activity suggestions for wide range of physical abilities.
Occupational Therapy

A. My student has difficulty with:



Typing on a keyboard. / Using a computer mouse.
Holding scissors. / Controlling the scissors and/or paper.
Copying work from the board. / Copying work from books.
Forming cursive letters. / Reading cursive writing.
Switching hands during fine motor tasks. / Fatigue during printing or other motor tasks.
Chewing on fingers or clothing. / Being bothered by clothing tags, bright lights or loud noises.
 Being overwhelmed by visual information. / Eating his/her snack or lunch.
Toileting independently. / Being bothered/dislikes certain foods (textures, temperatures, certain foods).
Organizing his/her work and/or locker.
Grasping/controlling his/her pencil. / Forming printed letters and numbers
Letter and/or number reversals. / Fluency of printing.
Grasping and manipulating small objects. / Grasping and placing objects with accuracy.
Completing puzzles. / Discriminating between shapes and other designs that are slightly different
Dressing for recess and/or gym.
Remembering information presented visually / Using both hands together (lacing/tying shoes, opening lunch container).
Classroom mobility and transfers

B. What strategies have been tried? Did they work or not work?

C. How can an Occupational Therapist help?

 Provide educational strategies in the area of productivity including:

 functional skills (meal preparation, laundry).

 prevocational skills (recycling, work experience).

 written communication (printing, handwriting, keyboarding).

 Assess and recommend strategies and/or accommodations regarding:

 safety issues and school accessibility.

 positioning in desk/wheelchair.

 sensory processing.

 fine motor skills.

 visual perceptual skills.

 planning and organizational skills.

 Promote independence and optimize participation in self-care activities (dressing, eating/drinking, toileting, hygiene).

 Provide assessment and strategies for enhancing oral motor and feeding skills.

Determine the need for and type of assistive technology that would support the student in their educational program.

Psychology

A. My student has difficulty with:



Blaming others. /  Remembering instructions / Memory for ideas and concepts
Reading / Expressing ideas in writing. / Being worried.
Mathematics / Poor schoolwork perseverance. /  Planning ahead.
Spelling / Overly literal understanding. / Staying in seat when expected.
 Starting tasks. /  Carrying out instructions /  Memory for rote facts or figures 
Completing homework. / Stealing. / Deliberately annoying others.
Threatens or intimidates /  Being overly quiet or passive /  Accepting praise, recognizing own success.
Lying / Arguing with adults. / Completing whole tasks.
Physical aggression (fighting)
Refusing to comply with rules/requests. / Needing teacher’s attention constantly.
 Organizing materials (desk, locker). /  Shifting between topics or activities.
 Listening to directions, attending to lecture. /  Being overly active, fidgeting, squirming.
Recognizing mistakes in academic tasks. /  Gathering needed materials for a task
Staying focused when noise and other activities are happening / Being sad (more than is expected for age).
Controlling emotions when necessary.(please clarify) / 
Understanding of social expectations.(please clarify)
Showing anger.(please clarify) / 
Reducing activity level when necessary.(please clarify)
Routines – classroom or transitions.(please clarify) / 
Having wide mood changes.(please clarify)
Missed time in school/attendance.(please clarify) / .
Interacting with other children.(please clarify) / 
Interacting with the teacher/other adults.(please clarify)
 Perseveration on narrow interests (please clarify).
Behaviour problems which complicate assessment of cognitive and academic abilities. (please clarify)



Additional comments: ______

B. What strategies have been tried? Did they work or not work?

C. How can a Psychologist help?

 Assess student’s current level of cognitive functioning/learning style and provide program recommendations.

 Assess student’s current level of adaptive functioning and provide program recommendations.

 Assess student’s current level of behaviour and provide program recommendations.

 Assess student’s social-emotional functioning and provide program recommendations.

 Consult regarding strategies to support learning in the classroom.

 Consult with the learning team regarding social skill development.

 Consult with the learning team regarding behavioural issues.

Speech Language Therapy

  1. My student:

Is difficult to understand.
Has difficulty forming sentences to express self
Makes sentences that sound immature.
Has poor vocabulary skills. / Repeats or prolongs sounds or words while speaking.
Is nonverbal.
Uses or needs to use an augmentative communication
Has difficulty understanding questions or commands
  1. What strategies have been tried? Did they work or not work?
  1. How can a Speech Language Therapist help?

Assess the nature and extent of student’s pre-verbal, verbal and non-verbal communication abilities.

Consult with the learning team to determine instructional strategies or technologies that will support communication with others, and the acquisition of language and literacy skills.

Determine the need for, the type of, and implementation of an augmentative/alternate communication system or assistive technology (e.g., software, Intellikeys, switch toys, etc.)

 Consult with the school staff regarding intervention strategies for communication programming.

 Provide assessment and strategies for enhancing oral motor and feeding skills (in collaboration with occupational therapist).

Education Consultant for the Deaf /Hard of Hearing and/or Educational Audiologist

  1. My student:

Has minimal to mild hearing loss.
 Has moderate to severe hearing loss
 Needs assistive technology. / Has profound hearing loss.
Is struggling academically
Uses an amplification system / Has difficulty communicating with his/her peers.
Has recently experienced hearing loss.
Does not speak grammatically correct



  1. What strategies have been tried? Did they work or not work?
  1. How can the consultant for the Deaf/Hard of Hearing help?

 Assess student’s academic abilities. /  Recommend curriculum modifications.
 Promote social skill development through consultation.
Provide information on sign systems (American Sign Language, Signed English) and in-services related to beginner sign language.

Recommend educational strategies, specialized learning materials and resources to address student specific needs.

 Provide consultation regarding individualized programming to enhance auditory, academic, sign and/or oral language skills.

 In-service school personnel regarding the educational implications of a hearing loss and integration of deaf and hard of hearing students into the regular classroom.

D. How can an Educational Audiologist help?

 Support the learning teams’ understanding of the educational implications of student’s hearing loss and the capabilities of personal hearing aids and FM systems.

 Interpret assessment and hearing aid fitting information from community audiologists.

 Evaluate acoustic environments and make recommendations for enhancing the learning environment.

 Make recommendations regarding the purchase, service and repair of FM systems.

 Provide classroom in-services for students on hearing loss, hearing aids and FM systems.

 Provide trouble-shooting support to schools regarding FM systems.

Provide in-services for school staff regarding anatomy and physiology of hearing and the use of hearing aids and FM systems

Nursing

My student:

Is on a special diet/at risk for choking/requires assistanceto feed (special consistency, meals cut up, allergies, G-tube, pump, assistance of another for feeding). 

Has a heart condition/blood pressure problems (pacemaker,regular blood pressure monitoring, low activity tolerance, tires easily, dizzy spells).

Has diabetes (insulin, blood sugar monitoring)

Requires special treatments, dressing changes, I.V. therapy, medication monitoring, and wound care.

Requires special medical devices or treatments to assist with breathing (oxygen, suction, tracheostomy, ventilator, oxygen monitor, pacemaker, and inhalers).

Has chronic pain and requires treatments/medications Related to pain relief (Rheumatoid arthritis, Cancer).

Requires assistance with elimination (help with toileting,catheterization, changing diapers, special bowel or bladder routine, regular toileting).

Additional Comments

How can a Nurse help?

Education Consultant of the Blind/Visually Impaired

  1. My student:

Is legally blind.
Has recently experienced vision loss.
Has limited visual acuity.
Has low vision. / Has a reduced field of vision.
Is having difficulty with orientation and mobility.
Needs appropriate reading and writing media.
Is struggling with academic learning.
Needs assistive technology
  1. What strategies have been tried? Did they work or not work?
  1. How can the Education Consultant for the Blind/Visually Impaired help with educational needs?

 Assess student’s functional vision to determine educational implications and programming.

 Interpret medical eye reports as they relate to educational environments.

 Consultation regarding educational resources and adaptations.

 Consultation regarding educational strategies for learners with multiple needs.

 Assess educational needs: academic, Braille, specialized equipment, functional academics.

 Registration with MRU (Materials Resource Unit). If student is eligible, recommend appropriate learning formats.

 Consult with school personnel regarding specialized material and/or equipment adaptations to maximize visual functioning and learning.

 Consultation regarding the development of student literacy programs and formats (Braille, large print, tape).

 Provide suggestions for adapting educational programs to facilitate inclusion.

  1. How can an Education Consultant for the Blind/Visually Impaired help with Orientation and Mobility needs?

 Assess orientation and mobility skills as they relate to the student’s environment: classroom, school, and community.

 Provide program suggestions and recommendations to school personnel and family to enhance the student’s level of skill in orientation and mobility.

 Provide information regarding use of sensory skills (functional vision, auditory, tactile, and olfactory) for orientation and mobility.

 Develop student programs that teach mobility concepts: sighted guide, self-protective techniques, cane skills, and independent travel based upon the student’s needs.

2012 – 2013 School Referral -- Page 1 of 7