| STUDENT:
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| AGE/DOB:
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| PHONE:
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ADDRESS: |
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| PARENT/GUARDIAN:
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| DATE:
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| SCHOOL:
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DISTRICT - Team:
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| Referral Source/Contact Person:
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| School Address:
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| School Phone:
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| Diagnosis:
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| Approximate Cognitive Functioning
Level:
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| Program Placement:
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Reason for Referral:
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What do you hope to gain from this
referral/assessment?
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| HEALTH CONCERNS |
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| Hearing status:
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| Visual functioning:
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| Seizures (frequency, duration, etc.):
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Medications:
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Overall health status:
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| COMMUNICATION CONCERNS |
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1. List student's current means of
communication and/or attempts to communicate and/or
make needs known (i.e.
signs, gestures, communication aide, symbol systems, vocalizations).
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2. How successful are communicative
attempts? Do you believe the student gets frustrated?
Are there persons
within this environment with whom the child may communicate effectively?
Please describe.
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3. Does the student indicate "yes"
and "no"? If so, please describe.
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4. Do you believe the student understands
more than he/she is able to express? Why?
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5. Are there activities in your class
which you feel the student cannot participate in or
participate equally
in due to speech involvement? Please describe.
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6. What would you consider the greatest
obstacle for the student in terms of academic achievement?
Please describe.
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7. Can the student match: (circle
those that apply)
Object to object?
Picture
Photo
Drawing: to Object? |
| 8. Check items below which student
can identify (by pointing or looking) when named:
Object
Photo
Pictures
Written Words
Other (specify)
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| Written Communications |
1. List the student's current means
of written communication.
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2. How successful are written communicative
attempts?
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Do you believe the student gets frustrated?
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Are some methods of writing more effective
than others? Please describe.
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3. Does the student have a way of
completing assignments with little or no writing required?
Please describe.
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4. Are there activities in your class
which you feel the student cannot participate in
or participate equally
in due to writing difficulties? Please describe.
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MOTOR CONCERNS |
1. How is the student positioned throughout
the day?
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2. If the student is in a wheelchair,
what type and with what adaptations?
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3. Briefly describe gross motor functioning
abilities (i.e. head and trunk control, mobility skills
[independent,
some support, total support]).
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4. Check items below that student
can perform from his/her most optimal position:
Accurate reach
Accurate point
Isolated finger movements
Cross midline with gaze
Cross midline with hand |
| 5. Which is the student's
preferred hand?
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| 6. Does the student maintain a steady
gaze for 7 seconds?
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| OTHER IMPORTANT INFORMATION |
1. What are the interests of the student?
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2. What types of toys/hobbies does
this student enjoy?
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3. What motivates this student?
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4. Other concerns and information
can you share?
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