1.  What is the student’s name, age, grade, school, does child have an IEP or 504? Where was child educated last school year (i.e., in district – get name of teacher; out of district – ask any relevant questions – did family move? Did child return from a specialized program, etc.)

2.  Who raised the concerns? (if needed, ask what their role is with the student – i.e., general education teacher, resource teacher, PE teacher, etc.)

3.  What are the concerns? (encourage the reporter to describe what they are worried about; allow this to be a free narrative and use reflective listening to summarize their concerns)

4.  Assess potential severity/interference with child’s educational performance — ask how much these issues are getting in the way of: (Consider asking them to rate the impact from 1-5 with 5 being the strongest negative impact.)

5.  Assess safety issues.  If this is an urgent situation or concerns suggest the student or others may not be safe, then enact an emergency plan as appropriate.  (Need a differential referral process here; for example, when does the referral go to another team – such as the positive behavior support team – instead?)

6.  Assess duration and persistence of concerns (if relevant). 

7.  What’s been discussed about the educational identification process so far (with the family, within the school team)

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