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Basic Info
Student's name
Your answer
Age
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Grade
School site/Classroom number
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Teacher's name
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Your arrival time
Time
:
Meet the student at
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Your dismissal time
Time
:
Student's end of day routine (Does your student get picked up? By whom? Do they go to after school care?)
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Do you get a 30 minute break? When?
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Academic or functional skills (What are they working on?)
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Favorite activities
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Social/Emotional/Behavioral
Baseline behavior for my student looks like
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Strategies to help keep my student at baseline
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Agitated behavior for my student looks like
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Outburst behavior might include
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Things you should avoid
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Class schedule and/or daily routine
Please either use the following three boxes to break up your student's routine, or the daily outline to give us the entire schedule at once
Morning routine
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Lunch routine
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Afternoon routine
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Daily outline (you may alternately use this space to give us a full outline of your student's day, please do not write up a paragraph but rather format as an outline i.e. bullets)
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Disability Intervention Services (DIS)/Pull Outs
APE (Please list teacher's name, days, and times)
Your answer
Speech (Please list teacher's name, days, and times)
Your answer
OI (Please list teacher's name, days, and times)
Your answer
OT (Please list teacher's name, days, and times)
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Counseling (Please list teacher's name, days, and times)
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Other (Please list teacher's name, days, and times)
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Health Needs/Assistance
Notes
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Medical Needs
Notes on Medical Needs
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Bathroom Routine
Notes on Bathroom Routine
Your answer
Communication
Notes on Communication
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