Clinton City Schools

PreschoolReferral/Intervention

Documentation Form

General Student Information

Student: ______Date: ______

Grade: ______Teacher: ______DOB: ______

Social Security #: ______NCWISE #: ______

School: ______

Parent(s): ______

Address: ______

Home Phone Number: ______Cell Phone: ______

Work Phone Numbers: Mother ______Father: ______

Primary Language Spoken in the Home: ______

Hearing Screening (Date/Results): ______

Vision Screening (Date/Results): ______

Health Screening (Date/Results): ______

Medical Diagnosis/Medications: ______

Are there gross or fine motor concerns?Yes or No

______

Are there speech-language concerns?Yes or No

______

Please provide specific concerns regarding this request:

______

______

______

______

______

______

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Parent Conference/Contact Record

A. First Contact / Attempt Date: _____/_____/_____

School Person Making Contact: ______Position:______

Type of Contact: _____ School Conference _____ Letter/Note _____ Home Visit

_____ Phone Call _____ Other: ______

Purpose: ______

Comments on Conference: ______

______

B. Second Contact / Attempt Date: _____/_____/_____

School Person Making Contact: ______Position:______

Type of Contact: _____ School Conference _____ Letter/Note _____ Home Visit

_____ Phone Call _____ Other: ______

Purpose: ______

Comments on Conference: ______

______

Has the student received a psychoeducational evaluation before? Yes No

If yes, what were the results from this evaluation? ______

______

______

______

Parental Notification of Screening Procedures Form Sent:

Notice Sent by: ______Position: ______Date: _____/_____/_____

Description of support the student is currently receiving:

_____ Speech Language Therapy_____Behavior Plan/Interventions

_____ After School Programs _____ Individualized Health Plan

_____ Emergency action Plan _____ English as Second Language (ESL)

_____ Outside Agency Involvement ______

_____ Other (please list): ______

Assessment Data:

  • For Preschool child, please attach most recent DIAL-3 Assessment Data
  • Please attach a copy of the most recent Creative Curriculum report.
  • Please attach any other informal assessment information that might be helpful.

Student Grades for Current Year:

  • Attach most recent progress report(s) for student.
  • Classroom Observation:

What would be the best day(s)/time(s) for someone to observe the student having the difficulties that you describe above? (May attach a copy of the student’s daily schedule if available): ______

______

Observer: ______Position: ______

Date: ___/___/___ Time of Day: ______

A. Activity Observed (check all observed)

_____ Free Play _____ Centers/Structured Play_____ Transition

_____ Meal Time _____ Circle Time _____ Nap Time

_____ Parent/Family Time _____ Solitary Play

_____ Outdoor Play _____ Small Group Activity

_____ Other: (specify) ______

______

C. Student Behaviors (check all observed)

_____ Attentive _____ Cries Easily _____ Neat Appearance

_____ Clings to caregiver _____ Careless _____ Doesn’t Complete Tasks

_____ Talks out of turn _____ Demands Excessive _____ Contributes to Class

Attention Discussion

_____ Easily distracted _____ Overactive, restless _____ Repetitive Behavior

_____ Talks Excessively _____ Short Attention Span _____ Friendly

_____ Immature Behavior _____ Withdrawn _____ Daydreams

_____ Works Well Independently _____ Displays Leadership Ability

_____ Tries to Control Others_____ Disruptive _____ Easily Frustrated

_____ Avoids Groups _____ Trouble Finding Place _____ Aggressive Towards

Children

_____ Cooperative _____ Speech Problems _____ Avoids Eye Contact

_____ Natural Curiosity _____ Unusual Language _____ Does not Follow Directions

_____ Spits _____ Bites _____ Temper Tantrums

_____ Shy _____ Takes Turns _____ Shares

Other: (specify) ______

______

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Additional Comments (if any):______

______

______

______

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Attach observation narrative to the back of the Referral/Intervention Documentationpacket.

Reason(s) For Referral/Areas of Concern

(Taken from NCDPI State EC Forms- Preschool Referral DEC 1 2b of 4)

Learning/Behavioral

__ difficulty remembering facts, details __fearful

__ asks for help too quickly __ repeats same problem solving strategy, even when

__ short attention span for age unsuccessful

__ quickly abandons playing with toys __ will not attempt difficult tasks

__ difficulty following directions __ difficulty making transitions from one activity to

__ destructive another

__ physically aggressive with others __ fearful of new situations

__ appears withdrawn __ cries easily

__ temper tantrums (describe) __ consistent inappropriate emotional reactions to

______situations/people

__ fights and/or bites __ plays poorly with others (explain)

__ provokes/aggravates others/defiant ______

__ takes inappropriate risks __ requires constant supervision

__ talks about hurting self or others __ talks excessively, attention seeking

__ repeats same behavior over and over (explain) __ other:______

______

Communication

__ difficulty using spoken language __ difficulty understanding language of others

__ nonverbal __ is not understood by unfamiliar listeners

__ unable to communicate basic wants and needs __ voice constantly sounds hoarse

__ is not understood by familiar listeners __ slow, labored speech

__ speech is choppy, stuttering __ drools constantly

__ has a vocabulary of less than 50 words __ frequently chokes on liquids, food

__ difficulty eating certain foods (list foods) __ frequent middle ear infections

______

Physical/Sensory

__ lacks age appropriate self-care (feeding, dressing/undressing, toileting, bathing)

__ impaired vision (explain) ______

date of last Opthamological exam: ______

__ impaired hearing (explain) ______

date of last Audiological exam: ______

__ lacks age appropriate gross motor skills

__ lacks age appropriate visual-motor skills

__ falls down easily, hurts him/herself frequently

__ lacks physical mobility at home/school

__ has seizures/epilepsy

__ cochlear implant: date of implantation: ______

__ overacts to typical sights, sounds, tastes, textures, etc. (explain) ______

__ primary mode of communication (circle): signing, cueing, auditory-oral/verbal

Summary of appropriate, relevant, research-based instruction and intervention services in the regular education settings:

Clinton City Schools requires interventions prior to the referral of any student - defined as:

  1. Before the referral process, the child is provided appropriate, relevant, research-based instruction and intervention services in regular education settings, with the instruction provided by qualified personnel; and

2. Documentation of repeated assessments of achievement or measures of

behavior is collected and evaluated at reasonable intervals, reflecting systematic assessment of student progress during instruction, the results of which were provided to the child's parents. Documentation of assessments should be in a format that indicates the results were measurable and observable.

3. If the student has not made adequate progress after an appropriate period

of time a referral for an evaluation to determine if the child needs special

education and related services shall be considered along with the

documentation of an adverse educational effect also required. An

“adverse effect” means that the progress of the student is impeded by the

suspected disability to the extent that educational performance is

significantly and consistently below the level of similar age peers.

There must be a minimum of two (2) interventions for each area of concern.

Regular education teachers are encouraged to consult with the Preschool Coordinator and/or Assistant EC Directorin determining and selecting appropriate interventions to use with identified student and when determining the most appropriate method or format to document student progress.

INTERVENTION DOCUMENTATION FORM

Intervention target/skill area(write in measurable terms): ______

______

______

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Intervention strategy/instructional practice (including resources needed as applicable):______

______

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Selected Intervention Approved by Team: Yes No Date: ______

Assessment instrument to be used to monitor progress: ______

______

Date for Baseline Data: ______

Note: Baseline Data should be obtained before intervention is begun.

Progress Monitoring data/scores:

Baseline / Week 1 / Week 2 / Week 3 / Week 4 / Week 5 / Week 6 / Week 7 / Week 8 / Week 9 / Week 10

Progress Monitoring Narrative/Explanation if needed: ______

______

______

Date reviewed: ______

Analysis of Intervention strategy (how did it work?): ______

______

INTERVENTION DOCUMENTATION FORM

Intervention target/skill area (write in measurable terms): ______

______

______

______

Intervention strategy/instructional practice (including resources needed as applicable): ______

______

______

Selected Intervention Approved by Team: Yes No Date: ______

Assessment instrument to be used to monitor progress: ______

______

Date for Baseline Data: ______

Note: Baseline Data should be obtained before intervention is begun.

Progress Monitoring data/scores:

Baseline / Week 1 / Week 2 / Week 3 / Week 4 / Week 5 / Week 6 / Week 7 / Week 8 / Week 9 / Week 10

Progress Monitoring Narrative/Explanation if needed: ______

______

______

Date reviewed: ______

Analysis of Intervention strategy (how did it work?): ______

______

Team Recommendation:

___ Progress in the general education curriculum is satisfactory-no further intervention needed. Teacher will continue to monitor student progress.

___ Progress is not satisfactory-refer for an initial evaluation.

___ The interventions and strategies, including instructional or environmental

modifications, are inadequate to address the students’ areas of concern. Current Intervention plan requires modification in order to continue.

Team memberPositionAgree/DisagreeDate

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