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REFERRAL TO SCHOOL-BASED TEAM Page 1 of this form is to be completed by the classroom
REFERRAL TO SCHOOL-BASED TEAM
Page 1 of this form is to be completed by the classroom
teacher(s) and submitted to the S-BT Chairperson
Classroom Referral
No
Student Name:
Yes
Student Referral:
Yes
No
Date of Birth
Grade:
     
     
     
Name(s) of Referring
Teacher(s):
     
School:
Designation
Date:
SBT Chairperson:
Code
     
     
     
     
Meeting Participants
Teacher(s)      
Student Support Teacher      
Resource Teacher      
Principal/Vice-Principal      
Aboriginal Education      
Counsellor      
     
SLP      
Psychologist      
CYFSW      
Instructional Coordinator      
Parent/Guardian      
     
Background Information/Cause for Concern
What are the students strengths/talents or specific interests?      
What are the areas of concern?
Academic
Social/Emotional Development
Physical Development
Other
     
Classroom-Based Assessment Information:      
Interventions & Supports already tried:      
Areas Where Assistance Is Needed
Autism Support
Differentiating Instruction & Learning
Literacy and/or Numeracy
Curriculum Based Assessment
Fostering Independence/Organizational Skills
Inclusive Practices
Learning Environment
Progress Monitoring
Transition Skills      
Fine Motor and/or Gross Motor Skills
Positive Behaviour Support
Sensory Dysfunction
Self-Regulation
Social Skills
Speech and Language
Hearing Support
Vision Support
Other      
Family Contact
Family has been contacted:
Yes
No
N/A
By Whom:      
Date:
     
Concerns discussed with parent(s)
Teacher’s Signature: ________________________________________________
Date:      

This form is to be submitted to the S-BT chairperson. Updated October 2013

This form is to be submitted to the S-BT chairperson. Updated October 2013

This form is to be submitted to the S-BT chairperson. Updated October 2013

School-Based Team: Action Plan

Meeting Date:      

Team Members in Attendance:      

TARGET AREA 1:      

TARGET AREA 2:      

Measurable Goal:      

Measurable Goal:      

Interventions:      

Interventions:      

Data Collection Method:      

Data Collection Method:      

Person(s) Responsible:      

Date of Follow-Up Meeting:      

Person(s) Responsible:      

Date of Follow-Up Meeting:      

School-Based Team Action Plan Guidelines

Target Area: What the student(s) will do. Conditions: When and how will the student perform the behavior?

Criterion: What is the expected level of performance?

Timeframe: What is the length of time anticipated for the student to reach the goal level?

Procedures/Arrangements: Determine what instructional procedures or strategies are to be used.

Measurable Goal: Write a goal to indicate the intended outcome of the intervention, including the direction, and the extent to which the target behaviour is to be changed.

Intervention

Location

Given amount of time the procedures will be implemented

Materials and strategies to be used

Data Collection Method: Indicate from where the data for intervention evaluation will be obtained. The method for data collection

When and how the data will be collected

Who will be responsible for doing the actual data collection and data summary or analysis

Case Manager:

School-Based Team Member who will follow up with those staff responsible during the course of the plan, prior to the follow-up meeting.

This form is to be submitted to the S-BT chairperson. Updated October 2013