Referral Process

REFERRAL PROCESS

ASSISTANCE FORM
LINK TO "INTERVENTION DOCUMENTATION" INTERVENTION TEAM SUMMARY REPORT SPECIAL EDUCATION REFERRAL PARENT REQUEST FOR AN EVALUATION TEAM DEFINITIONS REFERRAL AND PLACEMENT PROCESS FOR MOUNTAIN HEIGHTS ACADEMY SCHOOL HEALTH SCREENING FORM

THE COMMUNICATION DISORDERS PROGRAM: CRITERIA FOR PLACEMENT AND
TERMINATION

APACHE JUNCTION UNIFIED SCHOOLS

ASSISTANCE FORM


Date:
Referred by:
Classroom Teacher:
Student:	Grade:	DOB:
Parent's Name:	Phone:
Address
Primary Language:	Received ESL:


Date Cum. File Reviewed:
Number of Previous Schools Attended:
Attendance for past 2 Quarters:		Days Present:			Days Absent:
Retained:	No:		Yes:	Grade Retained:
Comments:


Primary Presenting Problems(s):
Reading:	Math:	Written Lang.:
Language:	Motor:	Aud. Process:
Behavior	Speech:	Emotional:


INTERVENTION PLANS:
Intervention:


Beginning Date	Duration:


Results:


Link to Printable Assistance Form

APACHE JUNCTION UNIFIED SCHOOLS

INTERVENTION TEAM SUMMARY REPORT


Date:
Student Name:
Teacher:	Grade:


Primary Problem(s):
Reading:	Math:	Written Lang:
Speech:	Behavior:	Auditory Process:
Motor:	Language:	Counseling:
Emotional:


Summary of Problem(s):


Strengths of Student:


Weaknesses of Student:


Recommendations:
Counselor:	Review Team:	Principal:	Resolved:


Persons Attending:


Team Chair Signature:


Link to Printable Intervention Team Summary Form

III. SPECIAL EDUCATION REFERRAL

A special education referral is a written request for an evaluation to determine if a student is eligible for special education services. The referral includes documentation of appropriate efforts to educate the student in the regular education program.

IV. PARENT REQUEST FOR AN EVALUATION

A parent may request an evaluation to determine if a child is eligible for special education services. If a verbal request is received from a parent, the district should assist the parent in making a written request. A written request for an evaluation, in any format, is considered consent for evaluation and triggers either a Formal Notice either denying the evaluation requested or acknowledging and acting upon the request for evaluation.

V. TEAM DEFINITIONS

MULTIDISCIPLINARY EVALUATION TEAM (MET)
The Met is a specialized term defined by Arizona Special Education statutes. MET refers to a school district team of persons, including at least one teacher or other specialist with knowledge in the area of suspected disability, who helps determine whether or not a child is eligible for special education based upon the evaluation results. The parent is an integral team member and input is required. The MET determines eligibility but not placement.

MULTIDISCIPLINARY CONFERENCE (MDC)
Members invited to the MDC may include, but not limited to; school psychologist, resource teacher, classroom teacher, parent, SLP, OT, PT and counselor. The function of the MDC is to determine educational placement, development of an IEP as appropriate and to make any changes within the educational placement of a child; such as re-evaluation, IEP modifications or termination from services.

INDIVIDUALIZED EDUCATION PROGRAM (IEP) TEAM

A team, including the parent (but not the parent’s advocate, friend, neighbor, social worker, etc.), which writes an appropriate educational program based on the evaluation results.

VI. REFERRAL AND PLACEMENT PROCESS FOR MOUNTAIN HEIGHTS ACADEMY

1. A student is identified with behavioral and/or emotional problems which interfere with
academic progress. (Classroom Teacher)

2. Modifications and interventions are attempted and documented. (Teacher)

3.   A comprehensive psychoeducational evaluation is completed within the last three years
      including measures of behavioral and emotional needs. Contained within the evaluation
      should be up-to-date reports from outside agencies, etc. (Psychologist)

4.   Based upon the evaluation, goals and objectives are created by a school team including
      teacher(s), psychologist, counselor, parents (when possible), and all other appropriate staff
      members. At this time "Referral Form" should be completed and sent (along with IEP and evaluation reports) to the School Psychologist. At this meeting, the MHA director/representative will explain MHA program and AHCCCS eligibility.

5.   MHA staff will make an observation in the current classroom setting.

6.   The team determines the least restrictive environment in which the goals and objectives can
      be addressed. If the team determines that a special self-contained ED/BD class is the least
      restrictive environment for the student, MHA placement will be pursued.

7. The MHA Psychologist will review the form and accompanying information with the
instructional and therapeutic staff at Mountain Heights Academy.

8.   If the student appears to be appropriate for the program, the school psychologist from the
      home school will work with the Director of Mountain Heights to arrange for an intake interview
      between Superstition Mountain Mental Health Center and the student’s family.
      The school psychologist will also work with the Director of Mountain Heights to arrange for the
      family and student to make an on-site visit, including a tour of the facility and a discussion of the       program.

9.   Upon completion of the intake interview and the on-site visit, the actual decision to place
      the student at Mountain Heights will be made. This may be made at the time of the on-site
      visit. (Psychologist & Director of MHA)

10. The psychologist from the student’s home school will arrange for transportation, based
upon the state date agreed upon by the family, school and Academy.

Please note:

Placement recommendations made by parents, teachers, administration and outside therapists, including therapists from SMMCH, are directed to the appropriate school team. The process follows the steps outlined above. There is no deviation regardless of who made the recommendation.

Placement decisions are made only after the proper interventions have been documented, after an evaluation is completed, and after the goals/objectives have been created. No placement decisions in special education are predetermined.

Whenever a school team makes a placement decision that requires a school change, the team should only go as far as identifying the need for a special class placement. The exact location of this special class (e.g. Mountain Heights) is not made until after the available and appropriate options have been explored, including intake interviews and site visits. Prematurely promising specific program placements is potentially counterproductive.
Mountain Heights Academy is not an emergency placement option. In fact, special education does not provide emergency placements. All placements are based upon evaluations, individual student need, and the least restrictive environment.

Any placement decision that results in a student’s removal from his/her home school is serious and affects the student’s civil rights. These decisions should not be based simply upon a desire to remove a student from a classroom or a school. We don’t “get rid” of students: we find the most appropriate programs for them.

APACHE JUNCTION UNIFIED SCHOOLS
SPECIAL EDUCATION DEPARTMENT
School Health Screening

Student: ___________________________ DOB: _________ Date: ________ Grade: _____

Dental Status: Good:_____ Needs Care:_____

Visual Acuity: Date Screened:____________ Pass:_____ Fail:_____

       Uncorrected Both Eyes 20/ _____        Corrected Vision 20/ _____
       Uncorrected Right Eye 20/ _____        Corrected Vision 20/ _____
       Uncorrected Left Eye 20/ _____        Corrected Vision 20/ _____

Near Acuity: Pass:_____ Fail:_____

Ocular Alignment: Pass:_____ Fail:_____

Auditory Acuity: Date Screened:__________ Pass:_____ Fail:_____

Frequency
500 Hz 1000 Hz 2000 Hz 4000 Hz

Right Ear ___ db ____ db ____ db ____ db

Left Ear ___ db ____ db ____ db ____ db

MEDICATION:_____________________ MEDICATION:_____________________

DOSAGE:_________________________ DOSAGE:_________________________

FREQUENCY:______________________ FREQUENCY:______________________

Physical conditions/limitations: ________________________________________________________

_______________________________________________________________________________

Comments: ______________________________________________________________________

_______________________________________________________________________________

_____________________________________
School Nurse

Link to Printable Health Screen Form

COMMUNICATION SKILLS PROGRAM:

The CommunicationSkills (CS) Program is for communicatively impaired students in the primary grades (K-3). The
intent of the program is to provide an appropriate educational experience for those children having a severe communication
disorder which impairs the student’s ability to communicate and acquire academics adequately within a traditional classroom or resource room. It does not include students whose communication challenges can be effectively addressed treated in a resource speech/language impaired program.

The communicatively impaired students is defined as a student who demonstrates average intellectual ability, but has a severe discrepancy between their language skills and intellectual abilities, and whose academic performance is severely impacted as a result. The communicatively impaired student does not include bilingual students who are having difficulty with English, but who are proficient in their primary language. In addition, the communication disorder must not be primarily a result of a visual, hearing, or motor handicap, mental retardation, emotional disturbance, or environmental, cultural, or economic disadvantage.

The Cummunicaton Skills Program shall be the student's base program, with assignment to a homeroom class for participation with age-level peers in specials, recess, and lunch. The goal of the program is to provide support/interventions/strategies to address needs in language in increase success in the acquisition of academics and peer relationships. As speech and language skills increase, students will spend extended periods of time in the general educational setting for academics..

CRITERIA FOR PLACEMENT AND TERMINATION

In order to place a child in the CS program, certain criteria must be met. The child must have a chronological age not
exceeding eight years, or second grade. The language disorder must not be primarily due to any of the following conditions:
mental retardation; emotional disturbance; or environmental, cultural, economic, or educational disadvantage. The IEP team
must determine that a student has a severe discrepancy between language skills and intellectual ability assessed through formal
and/or informal inventories, including a nonverbal IQ test such as the Leiter, or C-TONI.

   1.A student exhibits a severe receptive/expressive language deficit characterized by scores that are more than 3.0 standard
     deviations below the mean, (or greater than 50% below chronological age), on two or more assessment tools from the
     specified battery. For a CS placement, a specified battery must be used in order to assure consistency in placement.
     Additional assessment tools may be used to provide additional information (see: “Speech/Language Battery for CS
     Placement Consideration”). A child whose scores are less than 3.0 standard deviations below the mean, may qualify for
     placement in the Communication Skill Program if functional communication skills and/or intelligibility raise the
     severity.
   2.Intellectual ability will be assessed using non-verbal measures currently recognized as being valid and reliable for the
     language delayed student (i.e. Leiter, C-TONI).
          If test results are of questionable validity, as in the case of younger children, additional evaluation measures will be
          given for justification purposes. These include adaptive measures, criterion reference tests, and observational
          checklist/data.
          In some cases, the student with an IQ score below 85 may be considered eligible for placement in the CS
          program. In such cases the professional judgement concerning the student’s potential for higher intellectual
          functioning must be supported by additional data. Evidence of normal perceptual motor ability or performance
          indicating average abilities on another standardized measure may be considered possible justification for
          placement.
   3.The findings of standardized achievement tests, appropriate informal inventories, and classroom data indicate the student
     is performing significantly below expected learning levels in one or more of the following areas.
          Basic Reading Skill
          Reading Comprehension
          Mathematical calculations
          Mathematical reasoning
          Written communication.
   4.The student has been receiving consistent speech/language intervention for a minimum of one quarter of the school year
     before a referral can be made to the Communication Skills Program.
   5.Functional Communication skills may be significantly impaired as documented by the completion of observational data,
     language sample, etc.

Functional Communications Skills are a child's ability to communicate his basic wants and needs, as well as his ability to engage in successful verbal interactions with peers and adults. It incorporates the child's ability to initiate verbal interactions, adequately respond and maintain a conversational exchange. It includes the child's ability to use language effectively to label, make requests (for object, action), command, protest or deny. It also includes the child's ability to use language for social interatctions ( such as greeting, requesting permission, requesting a social routine, seeking comfort, to gain attention), for joint attention (to comment, request information/require, provide inoformation), or to inform about self.
The student demonostrates an inability to function within a traditional or resource classroom primarily due to receptive and expressive language impairment, as assessed by completion of the observation form by at least four individuals, including the classroom teacher, the home school SLP, a representative from the CS program (i.e. Teacher or SLP), and one independent observer.

.
6. Additional factor to consider: lack of intelligibility due to phonological disorder resulting in at least 80% unintelligibility.

Criteria for Termination
Placement in the Communication Skills program may be terminated when any one of the following criteria are met:

   1.Any child turning eight years of age during the school year will complete that year in the CS program and then must be
     placed in an different, yet appropriate program for the following year.
   2.The child will be considered for termination if the child demonstrates the ability to functionally communicate within a less
     restrictive environment (as determined by the completion of at least three observation forms- the reverse the criteria for
     placement), and scores better than 2.5 standard deviations or less on language measures; or ability to function in regular class with or without resource support.
   3.If intelligibility, and/or functional communication skills are no longer a vital concern in terms of the child’s ability to
     communicate.

Speech/Language Battery for C.S. Placement Consideration
The Core Battery must include one of the following receptive and one expressive vocabulary assessment tool, as well as at least two of the general language assessment tools, articulation assessment, and informal language sample/functional communication skills (information from observational checklists).

Vocabulary:
Expressive One Word
Expressive Vocabulary Test
Receptive One Word
Peabody Picture Vocabulary Test
Language:
Oral & Written Language Scale
TACL
CELF
PLS
TOLD
Articulation:
Goldman Fristoe
Khan-Lewis Phonological Analysis
Photo Articulation Test-3

Informal Language Sample Information/ Functional Communication Skills

Additional Tests (optional): To be used for more information, but not for placement in and of themselves.
Oral Periph Exam
Auditory Discrimination
TEEM
Boehm Test of Basic Concepts
Bracken
TAPS/TARPS
Any others as determined by the Speech/Language Pathologist


Link to Printable CD Observation Checklist

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