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Building Classroom Communities Referral
Student Name
*
Today's Date
*
Grade of Student (K-12)
*
Attending Building
*
Classroom teacher or person completing referral:
*
Is the IEP team considering a change in placement?
*
Yes
No
(If the team is considering a change in placement, the appropriate coach will reach out to review team concerns and data, and will assist in determining next steps.) Placement being considered:
*
Foundations/Alternate Assessment
Compass Academy
Verbal Behavior Classroom (elementary only)
ASD Supports (secondary only)
Homebound Services (medical need)
Area of concern:
*
Academic
Behavior
Academic Concerns
Academic area of concern:
*
Reading
Math
Written Language
Please identify the specific goals from the IEP in the academic areas of concern:
*
Please list the last 4 data points from the IEP goals in the academic areas of concern:
*
Please identify the assistance requested to address the academic concerns:
*
Review student data with teacher
Model an instructional lesson
Review curriculum options/needs for specially designed instruction
Review curriculum options/needs for specially designed instruction
Behavior Concerns
Please identify the specific area of concern:
*
Physical aggression
Verbal aggression
Self-injury
Non-compliance resulting in classroom disruption
Truancy
Truancy
Is there a documented mental health diagnosis?
*
Yes
No
Unknown
Please identify the specific goals from the IEP in the academic areas of concern:
*
Please list the last 4 data points from the IEP goals in the academic areas of concern:
*
How many office referrals has the student received this year?
*
0
1-3
4-6
7-10
11-15
16-20
21+
How many instances of seclusion or restraint have been required to ensure student safety and the safety of others this year?
*
0
1-6
7+
Have attendance hearings been held?
*
No attendance hearings have been held
Level 1
Level 2
Level 3
Level 4
Identify the assistance needed for behavior concerns:
*
Review current FBA/BIP with teacher
Align current needs with IEP and BIP goals
Observation of a student to collect specific information
Observation of a student to collect specific information