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Spaulding Educational Alternatives
If you have any questions or needs, please contact Tara Lavalette (tlavashs@buusd.org) or call us at 802-477-5030
18
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1
Person Submitting Form
Person referring student
Referrer email
Referrer phone
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2
Student
Student Name
Student Age
Please Select
7
8
9
10
11
12+
Please Select
Please Select
7
8
9
10
11
12+
Current student grade
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3
Contact Information
Please identify all possible individuals who have previously or are currently a part of the students team. You may need to scroll up/down or left to right to ensure all correct information is answered. Please note that an ROI (release of Information) will be required in the upload section for any outside agency contact.
Phone
Email
Length of relationship
Notes
Parent/Guardian #1
Row 0, Column 0
Row 0, Column 1
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 0, Column 2
Row 0, Column 3
Parent/Guardian #2
Row 1, Column 0
Row 1, Column 1
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 1, Column 2
Row 1, Column 3
Special Education Case Manager
Row 2, Column 0
Row 2, Column 1
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 2, Column 2
Row 2, Column 3
DCF Case Manager
Row 3, Column 0
Row 3, Column 1
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 3, Column 2
Row 3, Column 3
Outside Agency Case Manager
Row 4, Column 0
Row 4, Column 1
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 4, Column 2
Row 4, Column 3
Psychiatrist
Row 5, Column 0
Row 5, Column 1
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 5, Column 2
Row 5, Column 3
Psychologist
Row 6, Column 0
Row 6, Column 1
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 6, Column 2
Row 6, Column 3
Behavior Interventionist
Row 7, Column 0
Row 7, Column 1
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 7, Column 2
Row 7, Column 3
Outside Agency Support Person
Row 8, Column 0
Row 8, Column 1
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 8, Column 2
Row 8, Column 3
Other Team Member
Row 9, Column 0
Row 9, Column 1
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 9, Column 2
Row 9, Column 3
Other Team Member
Row 10, Column 0
Row 10, Column 1
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 10, Column 2
Row 10, Column 3
Other Team Member
Row 11, Column 0
Row 11, Column 1
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 11, Column 2
Row 11, Column 3
Parent/Guardian #1
Parent/Guardian #2
Special Education Case Manager
DCF Case Manager
Outside Agency Case Manager
Psychiatrist
Psychologist
Behavior Interventionist
Outside Agency Support Person
Other Team Member
Other Team Member
Other Team Member
Phone
Row 0, Column 0
Email
Row 0, Column 1
Length of relationship
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 0, Column 2
Notes
Row 0, Column 3
Phone
Row 1, Column 0
Email
Row 1, Column 1
Length of relationship
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 1, Column 2
Notes
Row 1, Column 3
Phone
Row 2, Column 0
Email
Row 2, Column 1
Length of relationship
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 2, Column 2
Notes
Row 2, Column 3
Phone
Row 3, Column 0
Email
Row 3, Column 1
Length of relationship
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 3, Column 2
Notes
Row 3, Column 3
Phone
Row 4, Column 0
Email
Row 4, Column 1
Length of relationship
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 4, Column 2
Notes
Row 4, Column 3
Phone
Row 5, Column 0
Email
Row 5, Column 1
Length of relationship
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 5, Column 2
Notes
Row 5, Column 3
Phone
Row 6, Column 0
Email
Row 6, Column 1
Length of relationship
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 6, Column 2
Notes
Row 6, Column 3
Phone
Row 7, Column 0
Email
Row 7, Column 1
Length of relationship
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 7, Column 2
Notes
Row 7, Column 3
Phone
Row 8, Column 0
Email
Row 8, Column 1
Length of relationship
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 8, Column 2
Notes
Row 8, Column 3
Phone
Row 9, Column 0
Email
Row 9, Column 1
Length of relationship
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 9, Column 2
Notes
Row 9, Column 3
Phone
Row 10, Column 0
Email
Row 10, Column 1
Length of relationship
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 10, Column 2
Notes
Row 10, Column 3
Phone
Row 11, Column 0
Email
Row 11, Column 1
Length of relationship
0-1 years
1-2 years
2-3 years
3+ years
0-1 years
1-2 years
2-3 years
3+ years
Row 11, Column 2
Notes
Row 11, Column 3
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4
Current Placement
Location
Contact Person (Case Manager, Director, etc...)
Contact email
Contact Phone Number
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5
Current IEP
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Max. file size
: 10.6MB
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6
Previous IEP
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: 10.6MB
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7
Most Recent IEP Evaluation
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: 10.6MB
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8
Most Recent FBA Evaluation
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: 10.6MB
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9
Most Recent Psycho-Educational Evaluation
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: 10.6MB
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10
Most recent Safety Plan/Behavior Plan
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Max. file size
: 10.6MB
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11
Release of Information Forms
Please combine all ROI's into one document to upload.
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Max. file size
: 10.6MB
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12
Comments and Notes
Please provide any additional comments regarding the student or any missing information.
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13
Interventions
*
This field is required.
Please list all academic and behavioral interventions, their overall success, and any relevant notes that you feel might be helpful in allowing our clinical team to develop a strong understanding of the students current needs.
Intervention Type
Overall Success
Notes
Intervention(s)
Row 0, Column 0
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 0, Column 1
Row 0, Column 2
Intervention(s)
Row 1, Column 0
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 1, Column 1
Row 1, Column 2
Intervention(s)
Row 2, Column 0
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 2, Column 1
Row 2, Column 2
Intervention(s)
Row 3, Column 0
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 3, Column 1
Row 3, Column 2
Intervention(s)
Row 4, Column 0
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 4, Column 1
Row 4, Column 2
Intervention(s)
Row 5, Column 0
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 5, Column 1
Row 5, Column 2
Intervention(s)
Row 6, Column 0
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 6, Column 1
Row 6, Column 2
Intervention(s)
Row 7, Column 0
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 7, Column 1
Row 7, Column 2
Intervention(s)
Intervention(s)
Intervention(s)
Intervention(s)
Intervention(s)
Intervention(s)
Intervention(s)
Intervention(s)
Intervention Type
Row 0, Column 0
Overall Success
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 0, Column 1
Notes
Row 0, Column 2
Intervention Type
Row 1, Column 0
Overall Success
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 1, Column 1
Notes
Row 1, Column 2
Intervention Type
Row 2, Column 0
Overall Success
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 2, Column 1
Notes
Row 2, Column 2
Intervention Type
Row 3, Column 0
Overall Success
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 3, Column 1
Notes
Row 3, Column 2
Intervention Type
Row 4, Column 0
Overall Success
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 4, Column 1
Notes
Row 4, Column 2
Intervention Type
Row 5, Column 0
Overall Success
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 5, Column 1
Notes
Row 5, Column 2
Intervention Type
Row 6, Column 0
Overall Success
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 6, Column 1
Notes
Row 6, Column 2
Intervention Type
Row 7, Column 0
Overall Success
Not Effective
Somewhat Effective
Effective
Very Effective
Not Effective
Somewhat Effective
Effective
Very Effective
Row 7, Column 1
Notes
Row 7, Column 2
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14
Student Strengths
Please describe the students current academic and behavioral strengths and successes that might be celebrated.
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Student Interests
Please list any and all interests, hobbies, or talents.
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Student Struggles
Please describe any identified social/emotional and academic areas where the student is currently struggling or needs support.
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17
Academic Supports
What supports does the student need in order to be successful academically?
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Social/Emotional Supports
What supports does the student need in order to be successful socially and emotionally?
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