Request edit access
JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
S.T.A.R.S. Referral
Referral requirements.
1. The Tri-County School Psychologist must notified of the referral.
2. The Tri-County Coordinator must give permission for the referral to be submitted.
If these steps have not occured, the referral must be placed on hold.
Sign in to Google
to save your progress.
Learn more
* Required
Referral requirements: Please check the items that have been completed.
*
1. The Tri-County School Psychologist must notified of the referral.
2. The Tri-County Coordinator must give permission for the referral to be submitted.
Required
The following questions must be completed in full in order for the S.T.A.R.S. team to review a student. The S.T.A.R.S. team is a support service for teachers.
Referral date:
*
MM
/
DD
/
YYYY
Referring professional:
*
Your answer
District
*
Fredonia
Neodesha
Coffeyville
Caney
Parsons
Independence
Thayer
Cherryvale
School
*
Your answer
Phone number:
*
Your answer
Teacher's email:
*
Your answer
Teacher's cell phone:
*
Your answer
School Psychologist:
*
Sally Mosier
Jen Tavanero
Kelsey Tronsgard
Jackie Arnold
Julie Fuller
Carrie Hurford
Jennifer Day
Katie Wilson
Coordinator
*
Sherry Dunlay
Ellie Cameron
Tim Heflin
Megan Robins
Jamie Whittley
Student's Name:
*
Your answer
Date of birth:
*
MM
/
DD
/
YYYY
Age:
*
Your answer
Grade
*
Your answer
IEP Date:
*
MM
/
DD
/
YYYY
Foster Care
*
YES
NO
Unknown
Mental Health
*
YES
NO
Unknown
Behavior Intervention Plan
*
YES
NO
Unknown
What type of help are you seeking from this team? (classroom setup, behavior programming, emotional regulation, material selection, etc)
*
Your answer
Exceptionality and Related Services:
*
Your answer
Medical Problems and/or Medications:
*
Your answer
Areas of Concern (please check all that apply)
*
interaction with adults
adjustment to school
disability-related behaviors
interactions with peers
accepting direction
behavior/noncompliance
following school routines
accepting correction
personal independence
Other:
Required
Describe your current concerns:
*
Your answer
What have you considered and/or tried to help the student with the areas of concern:
*
Your answer
List current level of academic performance and/or most recent classroom assessment data:
*
Your answer
Possible contributing factors (personal stressors, diagnoses, medications, on-going treatments, family stressors):
*
Your answer
Describe the student's daily schedule and special education program:
*
Your answer
Additional comments that will help assess the needs of the student:
*
Your answer
Effective classroom management happens in many domains, please rate yourself on a scale from strongly agree to strongly disagree on the following statements:
*
Your answer
I maximize predictability and structure in my classroom.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
I explicitly teach and follow predictable routines.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
My room is arranged to minimize crowding and distractions.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
I post, teach, review, monitor, and reinforce, a small number of positively stated expectations.
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
I provide a high rate of opportunities to respond during my instructions.
*
Strongly Agree
1
2
3
4
5
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
1
2
3
4
5
Strongly Disagree
I provide specific and contingent praise for academic and social behaviors. (e.g., following expectations)
*
Strongly Agree
1
2
3
4
5
Strongly Disagree
Please check any of the following that you use in your classroom:
*
Group Contingencies
Behavior Contracts
Token Economies
Rewarding Replacement Behavior
Planned Ignoring of Unwanted Behaviors
Visual Schedules For Whole Groups
Individual VIsual Schedules
Workbox Systems (If Appropriate)
Structured Teaching (first/then, charts, etc...)
Other:
Required
If you have any additional documentation regarding the student, please share it here:
Your answer
Participation
*
The STARS team is made up of several Tri-County professionals, committing a great deal of resources and time to these referral meetings in order to share expertise to give the best help we can offer. Please consider this when ensuring a child's full team is available to meet and participate in the discussion.
Please check for understanding
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of USD#484 Fredonia, Kansas.
Report Abuse
Forms
