subject_line
Behavior Universal Screener & Referral Guidelines
Student First Name
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Student Last Name
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Teacher First Name
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Teacher Last Name
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Teacher Email Address
*
Grade
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K
1
2
3
4
5
6
7
8
9
10
11
12
School
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CHS
CFA
SGS
PCIS
LES
LPS
MES
PCES
RES
SES
WES
ELC/CELC
Section 1: Please check the statements that apply to the student.
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Is taking medication
Excessive visits to school nurse
Consistent failure to complete or submit homework
Has failing or noticeably declining grades during the current school year
Was retained in grade
Poor or noticeably declining progress on standardized assessments
Signs of depression, withdrawal, inattention
Truancy problems, chronic absences, or skipping class
Negatively "stands out" academically from his/her same-age peers
Lack of peer relationships
Lack of teacher relationships
Negatively "stands out" behaviorally from his/her same-age peers
Subject of repeated reports of bullying as either the perpetrator or victim
Consistent lack of attention and focus
Is seeing an outside counselor, therapist, physician, etc.
There appears to be a need for a Behavior Intervention Plan or one has been implmeented
Section 2: Please check the statements that apply to the student.
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Failing or noticeably declining grades during the current school year combined with failing or noticeably declining grades during the previous school year.
Numerous or increasing disciplinary referrals for violations of the Student Code of Conduct
An increase in truancy problems, chronic absences, or skipping class over a multi-year period of time
Teacher/other school-based service provider suggests a need for counseling
Section 3: Please check any of the statements that are known to apply to the student.
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Has been hospitalized (particularly for mental health reasons, chronic health issues, alcohol or drug addictions, etc.)
Information that the child has been the victim of abuse
Information that the child has been in foster care/DHR custody
Is currently receiving outside counseling or school-based counseling from an outside agency
None of the above
Section 4: Please check the statements that apply to the student.
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MTSS/RTI progress monitoring data indicates little positive Response to Instructions for academics or behavior.
504 Plan accommodations have provided little benefit for academics or behavior.
The teacher/other school-based service provider suggests a need for an evaluation under 504 or IDEA or other services. Please attach a copy of the requestor report that includes the request.
Section 5: Please check the statements that apply to the student.
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The existing behavioral intervention plan has not been effective
Has received a DSM-5 diagnosis (ADHD, ODD, OCD, etc.). Please attach a copy of the diagnosis.
The parent has requested an evaluation. Please attach the parent's written request for an evaluation.
A private evaluator/therapist/service provider suggests the need for an evaluation or Services. Please attach a copy of the request or report that includes the request.
Upload report from section 4 if needed
Upload report from section 5 if needed
Upload written request from parent from section 5 if needed
Upload diagnosis from section 5 if needed
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