Wediko Children S Services

Wediko Children’s ServicesStudent Application - Teacher Form

Dear Teacher:

The enclosed Teacher Form is necessary for a student to be considered for the Wediko Summer Program. Although we recognize the burden of additional paperwork, your completed materials will help us evaluate the child for admission, formulate initial educational and treatment plans, and prepare final recommendations at the end of the program.

It would be particularly helpful if you included the latest intelligence and achievement scores for the applicant. Please also enclose any other reports or materials that would help us better understand this student.

Please note that Wediko must receive a copy of the current Individualized Education Plan (IEP) for any student who receives special education services.

After we receive your completed forms – along with the Parent and Therapist materials – we will arrange an interview for the student and his or her parents. No student can be interviewed until all parts of the application have been received.

Please forward the Teacher Form to:

Wediko Summer Program Admissions

72-74 East Dedham Street

Boston, MA 02118

Fax: 617-292-9272

IN ORDER FOR A STUDENT TO BE INTERVIEWED, WE MUST RECEIVE

ALL APPLICATION MATERIALS INCLUDING THIS TEACHER FORM!

Thank you for your time and cooperation in completing this material. Please call us at

617-292-9200 if you have any questions or comments.

Sincerely,

Mik Oyler

Director, Wediko Summer Program

Enclosure: Teacher Form

Student Application – Teacher Form

© Wediko Children's Services

Date:______

APPLYING TO:

The Wediko Summer Program

BACKGROUND INFORMATION:

Student’s name: ______

Age: ______Date of birth (Month, Day, Year): ______-- ______-- ______Grade in school: ______

Teacher’s name: ______School phone: ______- ______- ______

School contact person: ______Phone: ______- ______- ______

School name: ______Street address: ______

City: ______State: ______Zip: ______

EDUCATIONAL PLACEMENT INFORMATION:

Full-time mainstream classroom setting? Yes No

Does student receive special education services? Yes No

If yes, % time in special needs class: ______

Special education prototype, if appropriate: ______

Teacher-to-student ratio: ______Years at present school: ______

Days student was absent from school this year: ______Has student been suspended this year? Yes No

If yes, please explain: ______

______

If student is being considered for a new educational setting or school after Wediko, please give the name, address, and reason for the change:

______

______

Please summarize previous special education services that the student has had to date.

1. School: ______Teacher: ______Dates: ______

Reason for services: ______

1. School: ______Teacher: ______Dates: ______

Reason for services: ______

(Please summarize any additional special education services on an additional sheet.)

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Wediko Children’s ServicesStudent Application - Teacher Form

EDUCATIONAL PLAN:

The information requested in this section is necessary for basic curriculum planning and admissions decisions.

Assessments

Please provide the most recent assessment scores. This information is required for the application to be considered.

Test: ______Test: ______

Full scale IQ: ______Reading: ______

VCI: ______WM: ______Writing: ______

PR: ______PS: ______Math: ______Science: ______

Date given: ______Date given: ______

Academic Objectives

Reading: ______Math: ______

Please list educational objectives and current texts from which the student is working:

1. ______

2. ______

3. ______

1. ______

2. ______

3. ______

1. ______

2. ______

3. ______

Learning Difficulties

Please indicate any specific learning difficulties and/or disabilities:

Please describe instructional strategies that have been helpful / not helpful: ______

______

______

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Wediko Children’s ServicesStudent Application - Teacher Form

ACADEMIC INTERESTS

At Wediko, we utilize students’ interests to engage them in the academic curriculum. Please use this space to indicate the student’s academic interests. Examples might include: World War II, animals, science fiction, trains, comic books, volcanos, etc.

1. ______

2. ______

3. ______

1. ______1. ______

2. ______2. ______

3. ______3. ______

CLASSROOM MANAGEMENT STRATEGIES

Please use this space to indicate helpful strategies for managing this student in class. You might include additional information about: structuring the environment, attending to emotional needs, instructional strategies, and/or optimal group composition. Please also indicate if you have identified approaches that are not successful with this student.

CURRENT ADJUSTMENT:

From your point of view, what are the student’s best qualities?

1. ______

______

2. ______

______

3. ______

______

From your point of view, what are the student’s most serious problems?

1. ______

______

2. ______

______

3. ______

______

STUDENT’S STRENGTHS:

At Wediko, knowing the areas in which students excel is essential to providing effective treatment and education. Identifying the student’s strengths helps Wediko place him/her in the most appropriate group. Please rate the degree to which the student displays each of the following strengths.

0 = Not at all descriptive 1 = Slightly descriptive 2 = Fairly descriptive 3 = Highly descriptive

RISK FACTORS / BEHAVIORAL ISSUES:

At Wediko, we are particularly concerned about certain problematic behaviors. Information about these behaviors is essential for group placement decisions and individual treatment planning. Below you will find a list of some of these problem behaviors. Please rate the degree to which the student displays each of the following behaviors. Using this scale, write in one number for each item:

0 = Not at all descriptive 1 = Slightly descriptive 2 = Fairly descriptive 3 = Highly descriptive

THE MODIFIED OVERT AGGRESSION SCALE (MOAS)*

INSTRUCTIONS

Rate the student’s aggressive behavior over the past week. Check all and as many items as are appropriate.

Verbal aggression

___ 0 No verbal Aggression

___ 1 Shouts angrily, curses mildly, or makes personal insults

___ 2 Curses viciously, is severely insulting, has temper outbursts

___ 3 Impulsively threatens violence toward others or self

___ 4 Threatens violence toward others or self repeatedly or deliberately

Aggression against Property

___ 0 No aggression against property

___ 1 Slams door, rips clothing, urinates on floor

___ 2 Throws objects down, kicks furniture, defaces walls

___ 3 Breaks objects, smashes windows

___ 4 Sets fires, throws objects dangerously

Autoaggression

___ 0 No autoaggression

___ 1 Picks or scratches skin, pulls hair out, hits self (without injury)

___ 2 Bangs head, hits fists into walls, throws self onto floor

___ 3 Inflicts minor cuts, bruises, burns, or welts on self

___ 4 Inflicts major injury on self or makes a suicide attempt

Physical Aggression

___ 0 No physical aggression

___ 1 Makes menacing gestures, swings at people, grabs at clothing

___ 2 Strikes, pushes, scratches, pulls hair of others (without injury)

___ 3 Attacks others, causing mild injury (bruises, sprain, welts, etc.)

___ 4 Attacks others, causing serious injury

*Modified from Kay SR, Wolkenfelf F, Murrill LM (1988), Profiles of aggression among psychiatric patients: I. nature and prevalence. Journal of Nervous and Mental Disease 176:539-546

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Original document included as part of Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit. Copyright © 2010 American Academy of Pediatrics. All Rights Reserved. The American Academy of Pediatrics does not review or endorse any modifications made to this document and in no event shall the AAP be liable for any such change.

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Wediko Children’s ServicesStudent Application - Teacher Form

RESPONSE TO INTERVENTIONS:

Please rate how well the following statements describe this student’s response to school-based interventions.

Use this scale:

0 = Not at all descriptive 1 = Slightly descriptive 2 = Fairly descriptive 3 = Highly descriptive

Person or persons who completed this form: ______

All parts of the student application become part of a student’s clinical file, protected by and subject to release in accordance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

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