Northeast Metro Intermediate 916 Program Referral

Transcription

1 2540 County Road F East White Bear Lake, Minnesota Northeast Metro Intermediate 916 Program Referral Thank you for considering Northeast Metro Intermediate 916 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 respective Northeast Metro 916 Intermediate 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. Required Documentation The following required information must accompany this referral to begin the placement process. Please submit these items electronically: - Referral Form - Most current three year reassessment testing results and summaries - Medical Reports/Pupil Health Record/Immunization records - Current IFSP, IEP, FBA, Behavior Plan - Cumulative record information, including transcripts and behavior documentation - Hospital/residential placement reports (if applicable) - Outpatient Mental Health Diagnostic/Treatment Records - Birth Certificate (for initial placements in Kindergarten) - Home Language Questionnaire - District Referral form (if new to your district) - McKinney-Vento paperwork (if applicable) Additional Documents (needed prior to enrollment) - Most current Notice of Evaluation (PWN) - PWN for current IEP - State Testing scores and dates (attach a copy of reports) (if applicable) - IEP Progress/Home visit/ifsp progress - Signed PWN for change in placement For more information, contact: Megan Miller, Principal/Manager Phone Fax mmiller@916schools.org

2 Program Suggestion: Referral Date: STUDENT INFORMATION Last First Middle Date of Birth Age MARSS # Grade (at start date) Primary Disability Secondary Disability (if applicable) Student City State Zip Home Phone Cell Phone Gender Male Female Has student ever registered under a different name? (Please list) Are Parental Rights Terminated? (If yes, attach documentation) Current IEP date Current evaluation date Is the student: A ward of the county/state? Own guardian? Homeless? (include McKinney-Vento form) Migrant? Receiving ELL services? Open-enrolled? Student Race/Ethnicity: 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 Country of Birth Language(s) spoken at home Is the student Hispanic or Latino? If yes, at least 1 box must be marked YES and more than 1 box may be marked: American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White Please list current foster, group home, shelter, or residential living situations that the student has been assigned to (if applicable). Attach any reports, summaries, assessments, evaluations and grade reports Place of Residence Dates of Placement Contact Person Contact Phone Number Who has legal authority to make educational decisions? (Please attach documentation if needed) Has student previously been enrolled in a Northeast Metro 916 program? Yes No Page 1

3 PARENT/GUARDIAN INFORMATION Student Lives With: Mother & Father Group Home Foster Family Mother (and Stepfather if applicable) Relative (please list) Father (and Stepmother, if applicable) Other (please list) CUSTODIAL Parent/Guardian Information: Joint Legal Custody If yes, Name: Name: NON-CUSTODIAL Parent/Guardian Information: (If applicable; Please attach documentation) Status Visitation Contact No Contact Status Visitation Contact No Contact FOSTER/GROUP HOME Information: (If applicable; Custodial Rights documentation must be attached) Page 2

4 STUDENT BEHAVIORAL INFORMATION Number of suspension days in current school year: Please summarize the IEP team s basis for a placement recommendation in the more restrictive programming Northeast Metro 916 offers including specific considerations of home school district programming options and interventions that have been tried. Include any history of violent behavior. Provide information about three behaviors that prompted the referral Priority Behavior #1 Priority Behavior #2 Priority Behavior #3 Page 3

5 STUDENT MEDICAL INFORMATION Mental Health Information Has student had a diagnostic assessment? Date: Source: Diagnosis Anxiety Disorder Depression Pervasive Developmental Disorder Asperger Syndrome Encopresis Post Traumatic Stress Disorder Attention Deficit Hyperactivity Disorder Enuresis Schizophrenia Autism Spectrum Disorder Mood Disorder NOS Tic Disorder Bipolar Disorder Obsessive Compulsive Disorder Tourette Syndrome Chemical Abuse Panic Disorder Other: Other Medical Concerns Indicate any other health concerns or limitations Is the student on medication? DISTRICT INFORMATION Referring District Legal/Parent Resident District District Contact District Contact Phone Transportation Contact Transportation Contact Phone Student s Current Teacher Current Teacher Phone Name of person completing referral: Placement Approved By: Special Ed Director/Designee Please submit the completed form to Megan Miller at mmiller@916schools.org Page 4