PSYCHOEDUCATIONAL REFERRAL PROCESS Every year, each school will be assigned a number of psycho-educational assessment spaces. All referrals for psycho-educational assessments must go through the School Based Team. School Based Teams are expected to develop a prioritized list of students to be assessed during that school year. Schools should prioritize referrals according to the following guidelines: 1. Students who may have intellectual disabilities. 2. Students who require assessment to meet adjudication requirements for writing grade ten Provincial exams. 3. Students who demonstrate behaviour problems and may have learning disabilities. 4. Students who are having significant problems acquiring academic skills. 5. Students, whose original assessments are badly outdated and updated information is needed to plan a current individualized education program. REFERRAL STEPS: The child s case manager will complete the following steps for the referral process: Complete academic achievement testing (WIAT for children who are older that 7 and Brigance for children younger than 6). Attach a copy of the completed scoring page to the referral. Make sure that your scoring is accurate. Age norms should be used. Complete a Connors-3 rating scale and an ABAS protocol (one parent and one teacher). If behaviour is a concern also complete a BASC protocol (one parent and one teacher). Meet with the parent(s)/guardian(s) to have them complete the Referral Forms for Psychoeducational Assessment and the Consent to Release Information form. It is not absolutely necessary for the parents to have the child seen by the family physician in order to have the child scheduled for assessment. Arrange to update vision and hearing screening. Complete the Referral Form for Psychoeducational Assessment in collaboration with the classroom teacher and other support staff as appropriate. Attach all previous testing reports and/or medical reports as well as a current IEP if available to the Referral Form. Send in the complete referral package to Principal of Special Services. Do not send in referral information one piece at a time.
Request for Services Cover Sheet Case Managers use this sheet to help them ensure that referral packages are complete. Name of Student School Grade Teacher s Name Case Manager s Name Counselling Does this student have a special education designation? (If, specify) Psychological Assessment Service Requested? (Indicate or No ) If, the Case Manager will attach the following: Rule-Out Worksheet Educational Impact Statement Occupational Therapy Service Requested? (Indicate or No ) (Note: This service is provided by contracted therapists) If, the Case Manager will attach the following: Physiotherapy Parent Survey (if available) Rule-Out Worksheet Educational Impact Statement Checklist for OT/PT Services Service Requested? (Indicate or No ) (Note: This service is provided by contracted therapists) If, the Case Manager will attach the following: Parent Survey (if available) Rule-Out Worksheet Educational Impact Statement Checklist for OT/PT Services Service Requested? (Indicate or No ) (Note: This service includes assessment by a contracted psychologist) If, the Case Manager will attach the following: Parent s Checklist for Psychological Assessment Rule-Out Worksheet Educational Impact Statement All items on the Psychological Assessment Checklist Speech and Language Assessment Service Requested? (Indicate or No ) If, the Case Manager will attach the following: Parent Survey Rule-Out Worksheet Educational Impact Statement Checklist for SLP Services Hearing and/or Vision Screening Service Requested? (Indicate or No ) (Note: Vision and Hearing Screenings are required prior to Psychological Assessment) (Currently, access to hearing and vision screening is under construction) Person Completing this Form Date
Parent s Permission Form By signing this sheet, parents give permission for their child to receive services indicated. the Name of your Child School Date of Birth (Year) (Month) (Day) Names of Parents /Guardians Daytime Telephone Numbers Address: (P O Box) (Town) (Postal Code) E-mail (optional) Counselling (Parent or Guardian Initial) Psychological Assessment contracted through Dr. Linda Weaver (Parent or Guardian Initial) Occupational Therapy contracted through VIHA (Parent or Guardian Initial) Physiotherapy contracted through VIHA (Parent or Guardian Initial) Consultation with a Doctor (Parent or Guardian Initial) Speech and Language Assessment (Parent or Guardian Initial) Hearing and/or Vision Screening (Parent or Guardian Initial) Provide Assessment Reports (Parent or Guardian Initial) Name of Doctor(s) Name Agency As the parent or guardian of this student, I agree to the service(s) that I have initialed above. I agree to the Note to Parents and Guardians on the next page. I understand that copies of all assessment reports are retained by the school district and used to make educational decisions about my child, including placement in special programs. I agree to cooperate with the assessment process by completing additional checklists and questionnaires if requested. I understand that my child may be excused from class to access these services. Please print your name Signature Date _
Request for Services Notes to Parents and Guardians Case managers ensure that parents understand what they are when they sign the Parent s Permission Form on the previous page. agreeing A Note to Parents/Guardians Your child s Case Manager will ensure that this request is processed quickly and effectively, keep you up to date and answer any questions that you may have. However, due to limited resources, your child may not receive service or may be placed on a wait list. Providing effective service is a team effort and in order to provide the best service possible, service providers consult with your child s principal, teacher and special education worker. Service providers usually find it helpful to review your child s school record including report cards, previous psychological assessments, letters from physicians, discipline reports, occupational therapy reports, physiotherapy reports and speech/language assessments. During the course of providing service, service providers frequently wish to consult with professionals from other agencies; however, to ensure your right to privacy, we will only do this after we have asked for your permission. You are entitled to access all of your child s records and receive a copy of all assessment reports. The school and school district keep copies of assessment reports in compliance with School Board policy. Occupational Therapy and Physiotherapy services are under contract with the Vancouver Island Health Authority who maintains records in accordance with VIHA policy. Psychological Assessments are under contract with Dr. Linda Weaver who maintains records in accordance with her professional organization s standards. In most cases, the service provider will contact you by telephone using the numbers you provide. Depending on the service requested, you may be asked to complete checklists and questionnaires in addition to the ones included in this package. Sometimes we recommend that parents access services that we cannot provide, such as a visit to a medical doctor. Sometimes, the school or a service provider may want to consult with the doctor but they will ask for your permission first. Your prompt attention to recommendations made in the assessment reports helps us provide appropriate programming for your child. During a provincial audit of our special education services, we received high praise for establishing and maintaining positive working relationships with parents and our aim is to continue this standard of excellence. Therefore, we consider you an invaluable part of the education team and welcome your insight and suggestions.
Parent Survey Name of Your Child School Grade Your Name Date Please tell us about your child s strengths. Please tell us about your concerns for your child and how you expect this service to help them. What services or assessments has your child received in the past? What else do you want us to know about your child s strengths and needs?
Possibly No Unknown Possibly No No Assessments on file Request for Services Rule Out Worksheet Case Managers complete this worksheet as a guide in determining assessment and include as part of a Request for Services. Do not request a psychological assessment unless hearing and vision screenings are complete. priorities Name of Student School Grade Case Manager Date 1. Hearing: this student A. Recently passed a Hearing Screening. Date: B. Recently failed a Hearing Screening and was referred to a specialist. Attach details C. Has not been referred for a hearing screening. Reason: D. Other: 2. Vision: this student E. Recently passed a Vision Screening. Date: F. Recently failed a Vision Screening and was referred to a specialist. Attach details G. Has not been referred for a Vision screening. Reason: H. Other: 3. Complete the grid below by placing a mark in the appropriate boxes. Use the back of this sheet to explain if necessary. Observations at school support the possibility that this may be the primary cause of this student s needs. Assessment data in student s file supports the possibility that this may be the primary cause of this student s needs. Medical Condition Sensory or Motor Issues Attendance Patterns Linguistic Differences Emotional or Psychological Issues Other (Describe)
Request for Services Educational Impact Statement Case Managers complete this sheet with the SBT and parent if possible. answers help Service providers plan appropriate service and District determining the appropriate special education designation. Detailed Office in Important Note: The Referral Question below must be specific and comprehensive because it guides the service provider during assessment and treatment. Here are a few examples of what you might ask: This student is very distractible. Are there any physical changes that I can make to my classroom that will help this student attend to the learning? What math strategies will be effective to help this student with multiplication? Does this student qualify for a designation as a student needing Intensive Behaviour Supports? What are this student s cognitive strengths and weaknesses and how can we adapt the IEP to meet their needs? Does this student have either a learning disability or a cognitive impairment that accounts for the academic difficulties described below? Given this student s inability to follow age-appropriate verbal instructions, is there a receptive language problem or does this student have a poor working memory? Requests for service without adequate referral questions will be rejected, so consult with the Low Incidence Support Teacher or District Principal of Student Services to ensure this question is answered completely. Name of Student School Grade Case Manager Date Does this student have a special education designation? (If, specify and attach the current IEP) 1. Referral Question: 2. Please describe this student s strengths
3. Please describe this student s academic needs 4. Please describe this student s functional needs 5. Explain how this student s difficulties affect his or her ability to learn or function in the school. Include specific examples and attach supporting documentation such as a Planning Process document if one is completed 6. Please describe strategies and interventions that have already been used indicating their degree of success 7. Other relevant information
Checklist for Psychological Assessment When referring students for psychological assessment, Case Managers work with parents to complete these questions to ensure that the psychologist has as much information as possible Name of Student School Grade Teacher s Name Does this student have a special education designation? (If, specify) Name of special education teacher (if applicable) Name of special education worker (if applicable) Child s Primary Residence: Parent Home Grandparent Home Foster Home Group Home Other: Names of Parents or Guardians Address (Box Number) _ (Town) (Postal Code) Phone (home) (work) Contact person (if other than above) (Name) (Relationship) (Phone) Counsellor or Mental Health Worker (name) (agency) Pediatrician (name) (location) Case Managers ensure the following: The Referral Package is completely filled out and distributed as per the flow chart in Appendix 1. Items marked * below must be given to the psychologist on the date of her first visit unless the psychologist has agreed to another arrangement If the student is designated, a copy of the current IEP * Copies of previous assessments by Psychologists, Speech and Language Pathologists, Occupational Therapists and Physiotherapists* Copies of Medical reports, especially letters from pediatricians or child psychiatrists * A scored WIAT II, including the original examiner s brown booklet * An ABAS II protocol and, if behavior is being assessed, BASC-2 protocols * Conners 3 Behaviour Rating Scales (Teacher s and Parent s) protocols * If consultation or release of information will go beyond what is authorized by the standard Parent s Permission Form, ensure that additional permission is obtained
Questions for Parents: 1. What specific questions would you like to ask about his / her development and progress? 2. At what age (years and months) did your child reach the following milestones: Sitting up Crawling Walking Bike riding Talking Saying first word 3. What did she/he weigh at birth? 4. Was he/she born on time, early or late? 5. Was the mother healthy? List any medical complications. 6. If your child has a diagnosis from the doctor or other professional, what is it, when was it made and what is the doctor s name? 7. What medical conditions does your child have? 8. Please place a beside all those that apply. Please add comments where appropriate Medication (what kind): Illnesses Medical Conditions Does he/she have pain? Ear or throat infections Hearing loss Eye or visual problems Head injury Physical injury/ abuse Car accident Hospitalization (why?) Surgeries (what and when?) Drug or Alcohol use by parent during pregnancy (estimate frequency and amount) Heart problems Respiratory problems (eg. asthma) Seizures (what kind and how often or age they started) Sleep Problems
Bedwetting or incontinence Social Problems Emotional Adjustment Problems History for trauma or emotional abuse History for loss of parent or other Weight problem (over weight or under weight?) _ Eating problems or nutrition Diabetes or special diet? Behaviour Attention 9. Does your child need any special services? What kind? 10. Is there a family history for medical conditions that may affect your child? 11. Is there a family history for learning difficulties? 12. Do you have any further comments or concerns? (Attach extra sheets if necessary.) 13. My child has recently had a vision screen yes no 14. My child has recently had a hearing screen yes no 15. Would you like to meet with Dr. Weaver before the assessment, after the assessment or both before and after the assessment? 16. Would you prefer to meet in person or by telephone?