SUFFOLK AUTISM CADRE REFERRAL FORM
Observable Behavior / Rarely------DailyDoes the student demonstrate age appropriate social interactions? / 1 2 3 4 5
Does the student demonstrate effective communication skills? / 1 2 3 4 5
Does the student engage in self-stimulatory behaviors such as hand flapping? / 1 2 3 4 5
Does the student make extraneous or repetitive vocalizations? / 1 2 3 4 5
Does the student display rigidity to changes in the daily routine? / 1 2 3 4 5
Does the student have difficulty transitioning from one activity to another? / 1 2 3 4 5
Does the student exhibit significant aggressive or self-injurious behaviors? / 1 2 3 4 5
Does the student demonstrate significant or unsafe escape behaviors that require staff interventions (such as running from the room or climbing on objects)? / 1 2 3 4 5
Part I. To be completed by classroom teacher and e-mailed to school psychologist or building point of contact.
Student Name: ______Classroom Teacher: ______
Date: ______School:______
Attendance History
Health History
Sensory Screening
Previous Educational Assessments
Part II. To be completed by point of contact in collaboration with referring source and e-mailed to Sarah Snow ().
Current concern prompting this referral:
Past Services or Interventions:
Effectiveness of previous interventions for this problem:
Referring Source Signature: ______
Date sent to Point of Contact: ______
2011-2012 Point of Contact List
School / Point of Contact / e-mailBTWES / Catherine Johnson /
CES / Casey Benton /
DES / Casey Benton /
EFES / Sarah Snow /
FBES / Casey Benton /
HES / Graham Taylor /
KSES / Sarah Snow /
MBES / Heather Wintman /
NPES / Lisa Branchaud /
NSES / Sarah Snow /
OES / Ben Price /
SWES / Pam Ivey /
FGMS / Ben Price /
JFKMS / Graham Taylor /
JYMS / Ben Price /
KFMS / Ben Price /
KFHS / Heather Wintman /
LHS / Pam Ivey /
NRHS / Heather Wintman /