General Education Referral To Student Assistance Team

GENERAL EDUCATION REFERRAL TO STUDENT ASSISTANCE TEAM

PLEASANTS COUNTY SCHOOLS

Name ______Grade ______DOB ______Parent/Guardian ______

Area(s) of Concern (check all that apply):

Academic

□  Reading

□  Math

□  Spelling

□  Writing

□  Following directions

□  Study skills

□  Developmental

□  Attendance

□  Other ______

Physical

□  Hearing

□  Vision

□  Fine Motor

□  Gross Motor

□  Hyperactivity

□  Hypoactivity

□  Self-help/adaptive

□  Physical limitations

□  Health

□  Other ______

Emotional/Social

□  Aggressive

□  Withdrawn

□  Peer Relationships

□  Self image

□  Discipline

□  Disruptive

□  Inattention

□  Task Completion

□  Code of Conduct

□  Other ______

Communication

□  Articulation/speech

□  Oral Language

□  Fluency/stuttering

□  Voice

□  Listening skills

□  Other ______

Level of support currently being provided to student: Core Strategic Intensive

Statement of problem(s) in SPECIFIC, OBSERVABLE, MEASURABLE TERMS (i.e. Student reads 10 words per minute with 55% accuracy, student completes 1 of 5 assignments daily, student recognizes 3 letters, etc.)

______

Summary of Interventions utilized to date: (Describe specific interventions and student needs that have persisted despite intervention.) ______

Parent Involvement: (Describe parent/guardian contacts made prior to SAT referral.)

Date / Method of Contact / Reason for Parent Contact/Results

Required Data Attachments (must correspond to indicated Area(s) of Concern):

□  SPL Intervention Data – Strategic ____ Reading _____ Math Intensive _____Reading _____ Math

□  Formative and Benchmark Data results (STAR, curriculum-based assessments, behavioral data, progress charts, etc.)

□  Summative assessment results (WESTEST 2; Writing Assessment; ACT Plan; ACT Explore, etc.)

□  Previous Formal Evaluation by School or outside Agency

□  Work Samples (include analysis of errors and summary of concerns)

□  Grade reports

□  Discipline referrals

□  Attendance Reports (WVEIS)

Statement of Relevant School Experiences:

Previous School(s) attended ______Dates/Grades ______

Has the student been retained? Yes No If Yes, grade(s): ______

Has student received services in the past through WV Birth-3 or IDEA Part B (3-5 Year Olds)? Yes No

Does the student have a history of transfers from school to school? Yes No

Does the student have a history of excessive absences? Yes No

Other Relevant Information: ______

Referring Teacher(s) Signature ______Date to SAT Coor. ______

SAT Coordinator Signature ______Date Received ______

SAT Referral 09/2014

INITIAL SAT MEETING

PLEASANTS COUNTY SCHOOLS

Student Name ______WVEIS ______School ______Grade _____

Date of Meeting: ______

(Membership present document below)

Member Member

______

______

______

Meeting Notes: ______

______

Instructional/Support Intervention Plan

(Must address EACH area of concern on initial referral form- provide copy to all relevant team members; Attach additional page if more target areas are to be addressed.)

Level of Support:  Core  Targeted  Intensive
Interventionist(s): ______
Goal Statement (Must be linked to formative assessment results):
______
______
______
Initiation Date: ______/ # sessions/week: ______ / Length of session: _____ min
Progress Monitoring Schedule:  Weekly  Bi-weekly  Other ______
Intervention Procedures: ______
______
______
______
______

SAT Initial Meeting Page 1 of 2 rev. 09/2014

INITIAL SAT MEETING Page 2

Pleasants County Schools

Student Name ______Date ______

Level of Support:  Core  Targeted  Intensive
Interventionist(s): ______
Goal Statement (Must be linked to formative assessment results):
______
______
______
Initiation Date: ______/ # sessions/week: ______ / Length of session: ______min.
Progress Monitoring Schedule:  Weekly  Bi-weekly  Other ______
Intervention Procedures: ______
______
______
______
______
Level of Support:  Core  Targeted  Intensive
Interventionist(s): ______
Goal Statement (Must be linked to formative assessment results):
______
______
______
Initiation Date: ______/ # sessions/week: ______ / Length of session: ______min.
Progress Monitoring Schedule:  Weekly  Bi-weekly  Other ______
Intervention Procedures: ______
______
______
______
______

The SAT will reconvene on or before ______.

SAT Initial Meeting Page 2 of 2 rev. 09/2014

SAT REVIEW MEETING

PLEASANTS COUNTY SCHOOLS

Student Name ______WVEIS ______Date of Review ______

(Membership present document below)

Member Title/Relationship/Role

______

______

______

______

______

______

Part I: Evaluation of Instructional Intervention Plan

_____ Exceeded Expectation ____ Met Expectations ____ Made Some Progress ____ Made No Progress

Summary of Outcomes: ______

Part II: SAT Team Recommendations

_____ Student No Longer Requires SAT Intervention; Case closed.

_____ Continue Current Interventions as student’s needs are currently being met.

_____ Develop or modify Instructional/Support Intervention Plan/goals/strategies.

_____ Refer for Multidisciplinary Assessment and continue intervention.

If student is referred for Multidisciplinary Assessment:

Date of Referral ______Date Sent to CO ______

Date Received at CO ______CO Signature ______

(Attach copy of Prior Written Notice)

SAT Review Meeting 09/2014