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S.T.A.R.S. Referral
Referral form in order for the S.T.A.R.S. team to review a student. A service to teachers.
Referral date: *
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Referring professional: *
District *
School *
Phone number: *
Teacher's email: *
Teacher's cell phone: *
School Psychologist: *
Coordinator *
Student's Name: *
Date of birth: *
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Age: *
Grade *
IEP Date: *
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Foster Care *
Mental Health *
Behavior Intervention Plan *
What type of help are you seeking from this team? (classroom setup, behavior programming, emotional regulation, material selection, etc) *
Exceptionality and Related Services *
Medical Problems and Medications *
Areas of Concern (please check all that apply) *
Required
Describe your current concerns *
What have you considered and/or tried to help the student with the areas of concern: *
List current level of academic performance and/or most recent classroom assessment data: *
Possible contributing factors (personal stressors, diagnoses, medications, on-going treatments, family stressors): *
Describe the student's daily schedule and special education program: *
Additional comments that will help assess the needs of the student: *
Effective classroom management happens in many domains, please rate yourself on a scale from strongly agree to strongly disagree on the following statements: *
I maximize predictability and structure in my classroom. *
Strongly Agree
Strongly Disagree
I explicitly teach and follow predictable routines. *
Strongly Agree
Strongly Disagree
My room is arranged to minimize crowding and distractions. *
Strongly Agree
Strongly Disagree
I post, teach, review, monitor, and reinforce, a small number of positively stated expectations. *
Strongly Agree
Strongly Disagree
I provide a high rate of opportunities to respond during my instructions. *
Strongly Agree
Strongly Disagree
I engage my students in observable ways during teacher directed instruction. (ie, I use response cards, choral responding, and other methods). *
Strongly Agree
Strongly Disagree
I provide specific and contingent praise for academic and social behaviors. (e.g., following expectations) *
Strongly Agree
Strongly Disagree
Please check any of the following that you use in your classroom: *
Required
If you have any additional documentation regarding the student, please share it here:
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