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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.

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.
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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: *
MM
/
DD
/
YYYY
Age: *
Grade *
IEP Date: *
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/
DD
/
YYYY
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/or 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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