General Intervention Referral

 

Student:                                         Date:                                       DOB:                         Age:                                 

 

Teacher:                                         Grade:                                   Gender:               Ethnicity:                    

 

Language:                                               

 

  1. Concern:

_____ Excessive Absences                _____ Inconsistent class work     _____ Repeated failure to submit work

 

_____ Excessive Tardies                  _____ Excessive low grades        _____ Failure to progress

 

_____ Failure to master TEKS          _____ Speech difficulties            _____ Repeated failure to follow rules

 

_____ Consistent disruptive behavior                                     _____ Inappropriate peer interaction

 

_____ Other (describe)                                                                                                                          

 

 

  1. Goal:

What evidence will indicate that this student is making growth?

 

 

 

 

 

  1. Modifications and Adaptations:

 

Modifications and Adaptations in the General Education Classroom

Modifications and Adaptations

Dates: From/To

What evidence shows that the student is progressing or not progressing?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intervention in the classroom and through support programs (For example: Title One, After School Programs, LEP, Counseling,)

Interventions

Dates: From/To

What evidence shows that the student is progressing or not progressing?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intensive Intervention

Interventions

Dates: From/To

What evidence shows that the student is progressing or not progressing?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.    Progress Reports: (attach evidence to support your rating)

Rating

Date

Evidence
  • No Progress
  • Minimal Progress
  • Adequate Progress
  • Excellent Progress

 

 

 

 

 

 

 

5.    What needs to happen next?

 

  Continue Intervention

Try a different solution:

(describe) 

 

 

 

6.    Review of Previous Records and Current School Data

Cumulative File Notes:                                                                                                                                  

 

                                                                                                                                                                       

 

Attendance History:                                                                                                                                       

 

                                                                                                                                                                         

 

Grades:           Reading                                                          

                        Math                                                               

                        Writing/LA                                                     

                        Science                                                           

                        Social Studies                                                

 

Past services:

o      LEP

o      Special Education

o      Counselor

o      Dyslexia

o      504

o      Other, describe:

 

Standardized Test Results/TAKS:      Reading                                                          

                                                            Math                                                   

                                                            Writing                                               

                                                            Science                                               

 

7.    Family History

 

_____ Divorce _____ Illness _____ Illness of family member _____ Death in family _____ Family move

 

_____ New marriage _____ New birth ______ Removal from home ______ Poverty _____Abuse/Neglect

 

 

8.    Parent Participation

Child lives with:                                                                                                                                            

      Conference with parent:                                                                                                                           

      Phone conversation date(s):                                                                                                                     

      Parents were notified in writing (attach copy of letter):                                                                           

 

Arp ISD General Intervention Team and Referral Process

 

Overview

 

Our goal, in order to meet state and NCLB standards, is to meet the needs of all learners in the general education classroom.

 

Studies indicate that 30% of children entering school will need individual help; but fewer than half of these students have a disability to a degree that they require special education or 504 services.  The majority of these children will never be eligible for special education or 504 modifications.

 

It is no longer enough for educators to realize that a student has a learning issue and refer that student to a special program for the “fix”.  It is the responsibility of the teacher, once it is determined that a student needs assistance to provided assistance in a variety of ways and with a variety of methods BEFORE ever referring the child to a special program.  The teacher must be able to prove that assistance has been provided prior to the referral.  The General Intervention Referral must be completed, the General Intervention Team must meet, and the Intervention Plan carried out before a Special Education Referral can be considered.

 

Core Members of General Intervention Team

 

Classroom Teacher

Counselor

Principal

 

Optional Members

 

Parent

Student

Nurse

 

General Intervention Team Process

 

Step 1 – Identify the problem

Step 2 – Communicate with parent and child

Step 3 – Develop classroom interventions and implement

Step 4 – Request help from General Intervention Team

Step 5 – Complete referral

Step 6 – General Intervention Team Meeting

Step 7 – GIT Intervention implemented

Step 8 – Possible referral to 504, Special Education, Dyslexia, etc.

 

 

 

 

 

 

General Intervention Referral Instructions

 

  1. After exhausting all of your resources (see above), if your techniques are not resulting in desired student success, please continue below.
  2. Complete ALL sections of the General Intervention Referral.  Any incomplete information will result in the return of the referral to you.
  3. Attach work samples, intervention samples, and all relevant information.
  4. Upon completion of packet, turn in to the counselor/principal
  5. The General Intervention Team will meet and determine student’s intervention plan or further course of action.