Student Referral - The Alternative Program at The Wilder School
This form is only to be completed by a representative from the student's school. Parents/guardians are not to complete this form.
What is the name of the person completing this referral?
First Name
Last Name
What is the email of the person completing this referral?
example@example.com
What is the work telephone number of the person completing this referral?
What School District, Supervisory Union, or Agency does the student being referred come from?
Hartford School District
Windsor Southeast Supervisory Union
Windsor Central Supervisory Union
White River Valley Supervisory Union
Orange East Supervisory Union
Dresden School District
Lebanon School District
Mascoma Valley Regional School District
Rivendell School District
Other
Please check the following boxes of the people who have approved this referral.
Parents/Guardians
Superintendent
Director of Special Education
Other
If 'Other' was checked above, please provide the position or title of the person.
What is the date this referral is being completed?
-
Month
-
Day
Year
Date
What is the name of the student that is being referred?
First Name
Last Name
What is the date of birth for the student that is being referred?
-
Month
-
Day
Year
Date
What is the student's mailing address?
If different from the mailing address, what is the student's physical address?
What are the names of the student's parents/guardians?
Who are the adults that live in the child's household?
What is the phone number or main contact number for the household the student lives in?
If the parents/guardians have shared custody of the student, what is the phone number or main contact number for the second household the student lives in?
Please enter a valid phone number.
What grade is the student currently in or what grade did the student complete?
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Other
For a student being referred for grade 9, 10, 11, or 12, please upload the student's transcript.
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What is the primary reason this referral is being made? Please be in depth and specific.
What are the student's diagnosed disabilities?
What are the current levels of academic achievement in reading, math, and written language for the student being referred?
What are the student's cognitive scores and student learning profile?
What are the student's career interests, hobbies, or extra-curricular activitities?
Please describe the student's educational placements during their school career.
What related services does this student receive?
Occupational Therapy
Physical Therapy
Speech and Language Pathology
Mental Health Counseling
Assistive Technology
Behavior Consultation
Paraprofessional Support
Home Tutoring
Other
How many Rule 4500 events has the student experienced before this referral?
Please provide a summary of any pertinent, medical information regarding the student that is being referred.
Please describe the student's ability to get along and/or build relationship with others/teachers/peers.
If applicable, please provide information regarding attempted interagency involvement and custody status.
If the student has received therapy or counseling, who was the therapist, what is their phone number, and what philosophy of therapy do they subscribe to and have used with the student being referred?
What are the parent's/guardian's attitude to possible placement in the Alternative Program at The Wilder School?
If applicable, please upload the student's most current IEP, ESP, or 504 plan.
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If applicable, please upload the student's Psychological Evaluation.
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Please upload the student's most current Behavior Plan.
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What aspects of the Behavior Plan have been successful, not successful, changed or adapted?
What are the specific, measurable behavioral goals that will be pursued if the student attends the Alternative Program at The Wilder School?
What are the specific, measurable therapeutic goals that will be pursued if the student attends the Alternative Program at The Wilder School?
If different than the goals in the IEP, what are the specific, measurable academic goals that will be pursued if the student attends the Alternative Program at The Wilder School?
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