Macfarland Intermediate School

MacFarland Intermediate School

Intervention & Referral Services Team

Confidential

Please list below some specific, measurable goals and objectives you have for your student. Identify which is most important to you. We will choose one or more objectives from this list to keep our meeting focused and productive. Thank you!

I would like ______to be able to:

______

We’ll try to adhere to the following meeting format as closely as possible:

1.  Summarize problem (review info and share prior interventions) 3-4 min.

2.  Negotiate an objective 2-3 min.

3.  Brainstorm solutions 6-8 min.

4.  Clarify and refine 6-7 min.

5.  Select solutions 6-8 min.

6.  Develop action plan 7-10 min.

Please complete all forms and place in Meg Perrine’s mailbox or hand deliver to guidance office, room 209. Thank you!

To: Intervention and Referral Services Team

Referring Teacher: ______Referral Date: ______

Student: ______Grade ______D.O.B. ______

Parent/ Guardian: ______

Contact Info: Home- ______Work-______

Has parent been informed about I/RS referral? yes no

Is student new to the district? yes no

Reason for Request of Assistance (Must be school-based issues such as academics, behavior, school health)
Please list all teachers and/or specialists who have contact with this student:
____ BSI: Reading Writing Math ____ ELPAT
____ Speech & Language Specialist ____ ESL
____ School Counselor
____ Other ______

Student: ______Date: ______

Teacher: ______Grade: ______

Check each of the following items that are of concern to you or

that you have noticed regarding the above-named student.

Class Attendance:

______Frequent requests to leave class to: (check all that apply)

_____ go to nurse

_____ go to guidance counselor

_____ use lavatory

_____ other (please specify) ______

______Frequent absences

______Frequent tardiness

______Other (please specify) ______

Academic Performance:

______Difficulty with auditory memory

______Difficulty with visual memory

______Difficulty following directions

______Lacks organizational skills

______Failure to complete in-class assignments

______Failure to complete homework assignments

______Decrease in class participation

______Short attention span, easily distracted

______Cheating

Please Rank: 1- highest concern, 2- moderate concern, 3- low concern, 4- no concern

______Reading ______Social Studies

______Writing ______Mathematics

______Spelling ______Science

______Other ______

Behavior:

______Disruptive

______Poor peer relationships

______Lack of respect for others

______Lack of self-control

______Lack of respect for rules/ authority

______Blaming, denying

______Shows aggressive behavior

______Obscene/ inappropriate language, gestures and/or verbal abuse towards others

______Hyperactive

______Withdrawn

______Frustrates easily

______Poor self-image

Physical Symptoms:

______Sleeps in class

______Complains of hunger

______Unexplained, frequent physical injuries

______Deteriorating personal appearance

Student: ______Grade:______

Teacher: ______Date: ______

Date Implemented / Frequency / Results and Comments
NT- not tried S-successful U-unsuccessful
Classroom Environment
Seat away from distractions
Use of study carrel
Seat near instruction
Quiet muffs
Seat near positive peer
Support
Cross-age tutor
1-1 Adult Assistance
1-1 Teacher Assistance
Small group reinforcement
Peer “buddy”
Help after school
Mentoring program
Lunch group member
BSI (reading/ math)
Speech
ESL
Added incentives/ reinforcers
CST member observation
Referred to guidance
Referred to administration
Teacher Strategies/ Materials
Flash cards
Spelling aides
Math manipulatives
Proofreading checklist
Practice words
Sand letters
Wikki sticks
Use of timer
Tier II
Pre-teaching
Physical (tap shoulder to stay on task)
Repeat directions in own words
Non-verbal cues to redirect
Prewritten guidelines
Mnemonic devices
Increase response time
Repeat major points/ ideas
Provide verbal cues
Provide word banks
Supplemental software
Record daily assignment
Signed assignment book
Allow more time for tasks
Break down tasks
Other (explain)
Program Modifications
Reduced homework
Extra time
Reduce level of difficulty
Reduce quantity
Highlight key points/ directions
Use of calculator
Tape recorders
Reading tapes
Adapt teaching to learning style
Behavior Management
Individual conference w/ child
Guided Discovery
Positive reinforcement
Contracts/ Charts/ Points
Time out in room/ recess
Teamed w/ positive role model
Provide special recognition/ responsibility
Student calls/ writes parent
Sent to principal
Parent Communication
Daily or weekly progress reports
School conference
Telephone conference
Email
Other

What is the Student’s Wright Assessment Level (letter and grade equivalent)

Comments: