Referral packet - Northeast Metro 916

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Northeast Metro 916 Intermediate School District
Auditory/Oral Program Referral
Thank you for considering Northeast Metro 916 Intermediate School District Programming as a
placement option for your student. In order to provide the program with information in which to make
meaningful educational decisions, this referral packet needs to be completed in a thorough manner. This
information is necessary to process the referral and assure that appropriate procedures have been
followed. Upon receipt and review of this referral information, a representative from the Northeast Metro
916 Auditory/Oral Program will contact you to schedule a tour and next step planning. If essential
information is missing, the referral process and intake may be delayed.
Send completed packet to:
Deb Peterson
[email protected]
2540 County Road F East
White Bear Lake MN 55110
Phone: 651/415-5597 Fax: 651/415-5512
Required Information and Procedures
The following required information must accompany this referral prior to intake. Please indicate how you
will be sending these documents to 916.
Referral Form
Most current three year reassessment testing results and summaries, including FBA (if applicable)
Most current Notice of Evaluation
If most current three year evaluation does not include cognitive score, please provide report that does
Medical reports/Pupil Health Record/Immunization record. (Complete with intake packet)
Related service evaluation data (Speech, OT, PT, Audiological, Vision)
Current IFSP, IEP, FBA, Behavior Plan & last IFSP/IEP.
Psychological Reports: most recent given within past two years
IEP/IFSP Progress/Home visit
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NORTHEAST METRO 916 A/O PROGRAM REFERRAL
Referral Date:
Student First Name:
Student Middle Name:
Student Last Name:
Name of person completing the referral:
District Contact (Person who would know child the best in your district):
Current Intervention Setting:
□ Homebased
□ School
□ Other
□ Private
Programming Needed:
□ Individual Therapy (time/frequency)
□ Talking Time
□ Toddler (2 yr olds)
□ Pre & K (4 yr olds)
□ Kindergarten
□ Preschool (3 yr olds)
Referring District:
Legal/Parent Resident District:
District Contact:
Transportation Contact:
District Contact Phone:
Transportation Contact Phone:
Placement Approved By:
Special Ed Director/Designee
Parent Notification Date or Signature Date:
Current IFSP/ IEP Date:
Current Eval Date:
Student Birth Date:
Student Age:
Student Address:
City:
State:
Male □
Female □
Country of Birth:
Has student ever registered under a different name?
□ Yes
□ No
If Yes, please list:
Are Parental Rights Terminated?
□ Yes (If Yes, attach documentation)
□ No
Is the student a ward of the county/state? □
Is student homeless? □ Yes
□ No
Is student migrant? □ Yes
□ No
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Zip:
NORTHEAST METRO 916 A/O PROGRAM REFERRAL– Parent/Guardian Information
Student Lives With:
Mother and Father □
Mother (and Stepfather if applicable) □
Father (and Stepmother if applicable) □
Foster Family □
Group Home □
Relative □
(please list)
Other
□
(please list)
Custodial Parent(s)/Guardian Information:
Name 1:
Relationship to Student:
Email:
Address:
City:
Name 2:
Relationship to Student:
Email:
Address:
City:
Joint Legal Custody □
If yes, Name
Cell Phone:
Home Phone:
Work Phone:
State:
Cell Phone:
Home Phone:
Work Phone:
State:
Name
Zip:
Zip:
Non Custodial/Parent Information (if applicable):
(Please attach documentation)
Name 1:
Cell Phone:
Relationship to Student:
Home Phone:
Email:
Work Phone:
Address:
City:
State:
Zip:
Status of Non Custodial Parent
Visitation □
Contact □
No Contact □
Name 2:
Relationship to Student:
Email:
Address:
City:
Status of Non Custodial Parent
Cell Phone:
Home Phone:
Work Phone:
Visitation □
State:
Contact □
Foster/Guardian Group Home Information (if applicable):
Custodial Rights Documentation Must Be Attached
Name 1:
Cell Phone:
Relationship to Student:
Home Phone:
Email:
Work Phone:
Address:
City:
State:
Name 2:
Relationship to Student:
Email:
Address:
City:
Cell Phone:
Home Phone:
Work Phone:
State:
Who has the legal authority to make educational decisions?
(Please attach documentation if needed)
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Zip:
No Contact □
Zip:
Zip:
NORTHEAST METRO 916 A/O PROGRAM REFERRAL – School Information
MARSS #
Student Race/Ethnicity:
Is the Student Hispanic or Latino? □ Yes
If yes, at least 1 box must be marked YES and more than 1
box may be marked
□ American Indian/Alaska Native
□ Asian
□ Black/African American
□ Native Hawaiian/Pacific Islander
□ White
Check only one in this column:
□ American Indian or Alaskan Native
□ Asian or Pacific Islander
□ Black, not of Hispanic Origin
□ Hispanic
□ White, not of Hispanic Origin
Language(s)spoken at home:
Is Student Bilingual? □ Yes
□ No
□ No
LEP □
LEP Begin Date:
Primary Disability:
□ ASD 11
□ D-B 09
□ DCD Mild 02
□ DCD Severe 03
□ D/D 12
□ DHH 05
□ EBD 08
□ OHD 10
□ PI 04
□ SLD 07
□ SMI 16
□ SP/L 01
□ TBI 14
□ VI 06
□ No IEP 00
Secondary Disability:
□ ASD 11
□ D-B 09
□ DCD Mild 02
□ DCD Severe 03
□ D/D 12
□ DHH 05
□ EBD 08
□ OHD 10
□ PI 04
□ SLD 07
□ SMI 16
□ SP/L 01
□ TBI 14
□ VI 06
□ No IEP 00
Special Busing Needs: (From IEP Adaptions)
□ Wheelchair Lift
□ 1:1 Aide
□ Harness Required
□ 5 Point Harness Car Seat
□ 1:2 Aide
□ 1:3 Aide
□ Other
Please List:
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NORTHEAST METRO 916 A/O PROGRAM REFERRAL - Medical/Behavior Information
Mental Health Information:
Has Student had diagnostic assessment? □ Yes
Diagnosis: (check all that apply)
□ Attention Deficit Hyperactivity Disorder
□ Pervasive Developmental Disorder
□ Depression
□ Chemical Abuse
□ Post Traumatic Stress Disorder
□ Encopresis
Other
Does student have other health concerns
If yes, please indicate concerns or limitations
Is the student on medication?
□ Yes
□ No
Date:
□ Obsessive Compulsive Disorder
□ Autism Spectrum Disorder
□ Bipolar Disorder
□ Mood Disorder NOS
□ Schizophrenia
□ Tic Disorder
□ Yes
Source:
□ Anxiety Disorder
□ Asperger Syndrome
□ Tourette Syndrome
□ Panic Disorder
□ Enuresis
□ No
□ No
Behavior Information:
Directions: (Check behaviors of concern.)
Passive Behaviors (Self)
□ Drools
□ Inappropriately removes shoes/socks
□ Tears off buttons/zippers
□ Soils own property
□ Takes off all clothing while on the toilet
□ Doesn’t follow rules despite teacher/adult directive
□ Rips or tears own clothing/property
□ Refuses to wear clothing
□ Voids in public or general use areas
□ Drinks from toilet bowl
□ Gags, coughs, or chokes(self) for attention
□ Picks nose/scabs
□ Lack of work completion
□ Non attendance to school/skipping classes
□ Sleeps in Class
□ PICA
Social Behaviors
□ Stamps feet, bangs objects, slams doors
□ Runs away from teacher or group
□ Cries frequently
Antecedent:
□ Leaves seat and wanders without permission
□ Makes disturbing/bothersome/obnoxious noises (i.e.
growling)
□ Pulls own ears, hair, etc.
Aggressive Behaviors (Others)
□ Soils other’s property
□ Kicks, strikes, or slaps others
□ Spits on others
□ Throws objects at others
□ Uses objects as weapons against others
□ Deliberately tears up other’s possessions
□ Takes other’s possessions/property
□ Pushes, scratches, or pinches others
□ Pulls other’s hair, ears, clothing, etc.
□ Uses abusive language or yells at others
□ Chokes others
□ Bites others
□ Head-butts
□ Grabs other’s property
□ Bullies/threatens others
Self-Injurious Behaviors
□ Slaps or strikes self
□ Bumps head or other body parts
□ Bites or cuts self
□ Scratches, pinches, or picks at self(causing injury)
□ Pokes objects in own ears, nose or mouth
□ Smears fecal matter on self
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NORTHEAST METRO 916 A/O PROGRAM REFERRAL - Behavior Information
Emotional Distress Behaviors
□ Depression
□ Unusual Fears
List:
□ Withdrawal from others
□ Hyperventilates
□ Obsessive relationships/excessive ideation with staff
□ Obsessive/compulsive behaviors
Self Stimulatory Behaviors
□ Rumination
□ Chews or sucks on clothing, fingers, other parts of the
body or other inedible
□ Smells objects inappropriately
□ Makes noises (beyond what might be considered typical)
□ Repetitively manipulates objects
□ Plays with tongue
Is this an initial assessment for special education in state of Minnesota?
□ Yes
□ No
Please indicate the specialists that the home district and family would like to have included in the intake meeting
□ Teacher (EBD, SLD, DCD)
□ Psychologist
□ Social Worker
□ Nurse
□ Autism Resource Specialist
□ Speech/Language
□ Occupational Therapist
□ Physical Therapy
□ DAPE
□ DHH
□ Vision Impaired
□ Administrator
If a Functional Behavior Assessment is needed, please indicate past behaviors of concern:
1.____________________________________________________________________________________________
2._____________________________________________________________________________________________
Submit this form electronically by clicking here
Send completed packet to:
Deb Peterson
[email protected]
2540 County Road F East
White Bear Lake MN 55110
Phone: 651/415-5597 Fax: 651/415-5512
Save this form to your computer by clicking here
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