Vancouver School Board

PRE-REFERRAL INTERVENTION STRATEGIES Date: _______________

Student Information:
Age: _____ Birthdate: _________________ Gender: ____
Name: _________________________________________
Language in home: _______________________________
Parent(s): ______________________________________
Placement/Grade:_______________ Designation: ______
School: ________________________________________
School Case Manager: ____________________________
SIS Pupil #: ____________________________________
Teacher(s): _____________________________________

Concern:

Date Parents/Guardians contacted: _________________________________

Outcome:

Tier 1: To be completed by the classroom/subject Teacher (Check {} all that have been implemented)
Domain Strengths Needs

Social Interaction

Behaviour/Emotional
Functioning
Language/Communication

Academic/Cognitive

Other

Collect Information Adaptations & Strategies

I have:
Contacted the parents/guardians
Reviewed student file
Observed/recorded behavior/learning
Interviewed student/staff
Assessed performance in terms of strengths & needs
Collected samples of work
Other:
____________________________________
____________________________________
____________________________________
Adapt curriculum (difficulty, amount)
Adapt materials (literacy, numeracy)
Adapt teaching strategies (groups, pairing)
Provide extra time
Provide preferential seating
Adjust classroom layout/environment
Use of movement breaks
Use visuals to support program/outlines
Use positive reinforcement
Implement Positive Behaviour Supports (PBIS)
Other:
_______________________________________________

Outcomes/Effects of Adaptations & Strategies:

If further support is required, please proceed to Tier 2 (see other side)

Revised9/9/201612:56PM


Tier 2(a)

Service Provided by Non-Enrolling Staff (Resource Team Members, Counsellor):

Name Role yy/mm Type of Support

________________ _________________ ____ x / week, since _________for _______________________
________________ _________________ ____ x / week, since _________for _______________________

Assessments

Informal / Formal Assessments (e.g. KTEA, FBA) attach results

Reading: _____________________________________________________________________________
Oral language: _________________________________________________________________________
Writing: ______________________________________________________________________________
Math: ________________________________________________________________________________

Behavioural Observations:
Type of behaviour: ______________________________________________________________________
How often it occurs (frequency): __________________________________________________________
How long it lasts (duration): ______________________________________________________________
Who else is involved: ___________________________________________________________________
How severe it is (intensity): scale of 1-10 / 10 = severe __________________________________________
Where and when behaviour occurs (context): ________________________________________________

Recorded behavioural data: attach results

Assessment tools available through https://myvsb.vsb.bc.ca/vsbresources/curriculum/iep/Pages/Assessment.aspx

Targeted Intervention Plan

Actions
Date Started: ____________________________ Review Date: _______________________________
1. What: ____________________________________________________________________________
Who: ____________________________________________When: __________________________
Outcomes: ________________________________________________________________________
__________________________________________________________________________________

Date Started: ____________________________Review Date: _____________________

2. What:_____________________________________________________________________________
Who: ____________________________________________When: ___________________________
Outcomes: _________________________________________________________________________
___________________________________________________________________________________

School-Based Team

Tier 2(b)
Services Requested Date: __________________________
Educational Psychologist (Consultation / Assessment) _______________________________________
Speech Language Pathologist (Consultation / Assessment) ____________________________________
Behaviour Consultant ________________________
Inclusion Consultant ________________________
Other_______________________________________________________________________________

Revised9/9/201612:56PM