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:

Date of Birth

School:

Designation
Code

Grade:

Yes

No

Name(s) of Referring
Teacher(s):

Date:

SBT Chairperson:

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)

Teachers 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

School-Based Team: Action Plan

Meeting Date:

TARGET AREA 1:

Team Members in Attendance:

TARGET AREA 2:

Measurable Goal:

Measurable Goal:

Interventions:

Interventions:

Data Collection Method:

Data Collection Method:

Person(s) Responsible:

Person(s) Responsible:

Date of Follow-Up Meeting:

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