You are on page 1of 20

REFERRAL FORM

SPECIAL EDUCATION AND RELATED SERVICES
Form R-1 (Rev. 7/06)

Alverno: SCHOOL DISTRICT

X Initial □ Reevaluation
Name of child(Last, first, middle) Date of birth Grade School
Scott Liebscher June 7, 2009 1st Milwaukee School

Name of parent or legal guardian Address (Street, city, state, zip)
Sherri Liebscher 1234 W. North Street Milwaukee, WI 53216

Telephone Person making referral/title Date parent notified of intent to refer
area/no. General Education Teacher: Leanne March 1, 2016
414-555-0550 Bishop

Method of notifying parent of intent to refer Is an interpreter needed?

□ Conference X Phone call X Written □ Yes X No
Parent’s or adult student’s native language or other primary mode of communication if other than English
(specify):

Child’s native language or other primary mode of communication if other than English (specify):

Date of receipt of referral by school district/LEA: March 4, 2016
(month, day, year)
(Note: the date the district receives the referral begins the 15 business day timeline in which to complete the
review of existing information and notify the parents of whether additional assessments are needed.)

State reason you believe this child has a disability (impairment and a need for special education) - such
as academic and non-academic performance and medical information; any special programs, services,
interventions used to address this student’s needs and the results of those interventions, etc.

As noted by the general education teacher, Scott exhibits social, emotional, behavioral
functioning that so departs from generally accepted age appropriate norms in the following the
areas: social relationships and classroom adjustments. Data recorded for frequency, intensity,
and duration, for the following behaviors: aggression, emotional regulation, and interaction with
peers; supports the basis for a referral for testing for an Emotional Behavioral Disability. Prior
to intervention, Scott’s defiant aggressive behavior occurred 10 – 15 times per day. With
interventions such as, teacher proximity, sensory interventions, modified activities, visual
schedule, and extra time, Scott continues to exhibit aggressive behavior, however they have
decreased to less than 5 times a day.

If the child is transitioning from a Birth to 3 Early Intervention Program, and the district was invited by the
designated lead agency to participate in the transition planning meeting, document the date of the meeting
and who attended for the LEA or explain why the LEA did not attend:
X N/A
NOTICE OF RECEIPT OF REFERRAL AND Notice sent with Statement of
START OF INITIAL EVALUATION Parental Rights: TP-5/7/2016
Form IE-1 (Rev. 12/10) (Initials/Date)

Alverno SCHOOL DISTRICT
[If you need this notice in a different language or communicated in a different way, or have
questions about this notice, please contact _________________________ at ____________________.]

Dear Sherri Liebscher

On March 1, 2016 , the school district received a referral to evaluate your child Scott Liebscher to
determine whether he/she has a disability (impairment and need for special education). The individualized
education program (IEP) team is responsible for this evaluation and will conduct this evaluation at no cost
to you. You are a participant on the IEP team. You may include others on the IEP team who have
knowledge or special expertise about your child.

You and your child (if appropriate) are IEP team participants
In addition, the following people are being appointed to the IEP team by the school district
Role Name, if known
Representative of local educational Melanie Facinger
agency (LEA) – authorized to commit the
resources of the LEA
Special Ed. Teacher(s) Trinette Paige

Regular Ed. Teacher(s) Leanne Bishop

Related Services Personnel

Others: Psychologist Melanie Facinger

For SLD evaluation using response to
intervention only*, a licensed person
who is qualified to assess data on
individual rate of progress using a
psychometrically valid and reliable
methodology.
For SLD evaluation using response to
intervention only*, a licensed person
who has implemented scientific, research-
based or evidence-based, intensive
interventions with the referred pupil.
For SLD evaluation using response to
intervention only*, a licensed person
who is qualified to conduct individual
diagnostic evaluations of children.
*A public agency may designate a public agency member of the IEP team to also serve in these roles, if criteria are met.
Other options, if any, such as the selection of IEP team participants which were considered and the
reason(s) they were rejected and a description of any other factors relevant to the proposed action:
X None
IEP team participants will first review existing information available on your child, including information
provided by you. The IEP team will then determine what, if any, further evaluation is necessary to assist in
making a determination of whether your child has or does not have a disability and his or her educational
needs. You will be sent a notification of this determination within 15 business days of the school district
receiving the referral to evaluate your child. This notification will be sent by March 20, 2016.
(month/day/year)

If the IEP team determines that additional assessments and other evaluation materials are necessary, the
school district needs your written consent (permission) before administering any assessments or other
evaluation materials to obtain further information about your child. You will be informed about what
assessments or other evaluation materials will be given before they are administered. You will also be
informed of the names of the individuals who will conduct those evaluations, if known at the time of the
notice. Upon completion of the evaluation the IEP team will prepare an evaluation report which will
include documentation of your child’s eligibility for special education. You will be provided with a copy of
the evaluation report.

Within 60 calendar days of receiving your consent for evaluation or being provided with a notice that no
further assessment of your child is necessary, the IEP team will meet to determine whether your child has a
disability and to identify his or her educational needs. If the IEP team determines that your child is a child
with a disability, the team will meet to develop an IEP to address your child’s needs and determine a
placement to carry out the IEP within 30 calendar days. You will be provided with a notice of placement
and a copy of your child’s IEP. The school district needs your written consent (permission) before initially
providing special education to your child. If it is determined that your child is not a child with a disability,
you will be provided with a notice of that finding.

If at any point during an IEP team meeting to determine your child’s eligibility for special education,
develop an IEP, or determine a placement, you or other IEP team participants believe that additional time is
needed to permit your meaningful involvement, additional time will be provided subject to the time
limitations described above. This IEP team process may be concluded in one meeting or may require more
than one meeting depending on individual circumstances.

You and your child have protection under the procedural safeguards (rights) of special education law.
Please read the brochure of parent and child rights enclosed with this notice. In addition to district staff,
you may also contact Melanie Facinger at 414-555-0550 if you have questions about your rights.

Sincerely,

Melanie Facinger
School Psychologist

Revised 10/13/06
WORKSHEET FOR CONSIDERATION OF EXISTING
DATA TO DETERMINE IF ADDITIONAL ASSESSMENTS
OR EVALUATION MATERIALS ARE NEEDED
Worksheet EW-1 (Rev. 7/06)

Alverno: SCHOOL DISTRICT

Name of student Scott Liebscher

(Note: If a meeting is held to consider existing data and this form is used as documentation of that
meeting, complete I-3, “Evaluation Report and IEP Cover Sheet” and sections I and II below. If no
meeting is held, this form is used to document the input and decision of the IEP team participants.
Complete sections I, II, III, and IV and the name of the person completing the form).

I. List of information/reviewed:
Classroom/Recess Observation
Classroom Interventions and Results
Battery of test to include but not limited to: psychological, intelligence, and achievement
scores.
Behavior and sensory processing Assessments

II. Action to be taken as a result of review of considering the existing information/data:
□ Additional assessments or other evaluation materials are needed
X No additional assessments or other evaluation materials are needed

III. Documentation of parent involvement (including dates and method) and their input:

IV. List of other IEP team participants involved and their input (including dates):

Revised 10/13/06
Worksheet completed by Trinette Paige / Special Education Teacher
EVALUATION REPORT
Form ER-1 (Rev. 10/06)

ALVERNO SCHOOL DISTRICT

Name of Student: Scott Liebscher

TYPE OF EVALUATION: X Initial □ Reevaluation
DATE ON WHICH ELIGIBILITY DETERMINATION WAS MADE: May 7, 2016
(month/day/year)

THIS EVALUATION REPORT AND DETERMINATION OF ELIGIBILITY INCLUDES THE
FOLLOWING (check all that apply)

X Information from review of existing data □ Additional documentation required when
child is evaluated for a specific learning
disability
X Information from assessments and other sources □ Documentation for determining Braille
needs for a child with a visual impairment
X Determination of eligibility for special
education

INFORMATION FROM REVIEW OF EXISTING DATA

A. Summary of previous evaluations
N/A

B. Information provided by parents
Family reports Scott has frequent aggressive and defiant behavior. Due to behavior, family does not take
him out into the community. Scott refuses to participate in leisure activities including drawing, coloring, and
cutting, appropriate for his age.

C. Previous interventions and the effects of those interventions
Home: Scott is placed in a time-out chair, as a consequence for behaviors, however it may take up to 2
hours for Scott to regulate emotions and return to family routine. Reduction in demands resulted in more intense
but less frequent tantrums.

School: Teacher proximity, extra time for compliance, modified activity, encouragement, buddy system,
visual schedule, short time-out when positive interventions were not effective, and sensory intervention, resulted
in a decrease in aggressive reactions (hitting, kicking, spitting) from 10 – 15 times a day to less than 5 times per
day. Decrease in outburst responses when frustrated/angry with the ability to talk through situations and respond
to staff and requesting bean-bag chair 50% of 9 possible opportunities.

D. Current classroom-based, local or state assessments: N/A

Revised 10/13/06
E. Current classroom-based observations
Three two-hour observations were conducted during the regular education classroom’s morning routine. During
this time the following behaviors were observed:
Day 1 Day 2 Day 3
Refusal to join any activity Sat apart from group Sat apart from group
Yelling, screaming, kicking No yelling, screaming, or Did not join center activity
Throwing items Interrupting during calendar. 15 verbal outburst
Knocking over chairs Physical aggression and verbal yelling “I’m going to kill you”
Trying to leave the classroom refusal toward teacher during 1 tantrum for 5 minutes
Hiding in classroom and under table redirection to center time and 3 physical threats toward peers
Refusal to join activity when asked group activity. and teacher
10 minute engagement of self-selected No physical/verbal aggression
activity toward peers.
Physical Altercation with peer over a toy

F. Observations by teachers and related service providers
Data collected over 7 days for a 15 minute period shows that Scott watched others play, ran around alone, or sat
on the ground singing and humming. There were no interactions with other students and Scott refused to join
when prompted by recess supervisor.

Revised 10/13/06
INVITATION TO A MEETING OF THE
INDIVIDUALIZED EDUCATION PROGRAM (IEP) TEAM
Form I-1 (Rev. 10/06)

Alverno: SCHOOL DISTRICT
[If you need this invitation in a different language or communicated in a different way, or have
questions about this invitation, please contact________________________ at ____________________.]

Dear: Sherri Liebscher Date April 1, 2016

You are a participant on the IEP Team which will meet to address the educational needs of your child, Scott
Liebscher. IEP team meetings must be held at a mutually agreeable time and place. An IEP team meeting has
tentatively been scheduled for the following date May 7, 2016, time at 9:00am, Milwaukee School and location
1234 W. North Street Milwaukee, WI. If these meeting arrangements are not agreeable to you, please call
Melanie Facinger at 414-555-0550. You may bring other people who you believe have knowledge or special
expertise about your child to the meeting with you. If your child is transferring from a Birth to 3 Early
Intervention Program we will, at your request, send to the Birth to 3 coordinator or other representative an
invitation to the IEP meeting.

The purpose of this IEP team meeting is (check all that apply):

EVALUATION AND REEVALUATION
X Determine initial eligibility for special education
□ Determine continuing eligibility for special education
INDIVIDUALIZED EDUCATION PROGRAM (IEP) (if student is eligible)
X Develop an initial IEP
□ Develop an annual IEP
□ Review/revise IEP
□ Transition – the consideration of postsecondary goals and transition services
(required for students beginning at age 14)

PLACEMENT (if student is eligible)
X Determine initial placement
□ Determine continuing placement
OTHER
□ Review existing information to determine need for additional assessments or other evaluation
materials (meeting optional)
□ Conduct a manifestation determination (check appropriate boxes under IEP and placement if
changes in either are contemplated)
□ Determine setting for services during disciplinary change in placement (must also check
appropriate boxes under IEP & placement)
□ Specify: _____________________________________________________________________
Revised 10/13/06
Revised 10/13/06
If transition is checked as one of the purposes of this meeting, your child will be invited to attend. Because you
provided your consent we are also inviting representatives from the following agencies who may assist in the
transition planning for your child: □ None
____________________________________________________________________________________
Agency Name (if known), and Title/Position

_____________________________________________________________________________________
Agency Name (if known), and Title/Position

If at any point during this meeting you or other IEP team participants believe that additional time is needed to
permit your meaningful involvement, additional time will be provided. Decisions related to the purpose(s)
checked above may be made in one meeting or may require more than one meeting, depending on individual
circumstances. In addition and upon request you may receive a copy of the IEP team’s most recent evaluation
report.

The following individuals have been appointed as IEP team participants and will attend the meeting:

Leanne Bishop Trinette Paige
Name/Reg. Ed. Teacher Name/Sp. Ed. Teacher

Melanie Facinger Sherri Liebscher
Name/LEA Representative Name/Parent

Melanie Facinger ________________________________________
Name/Psychologist Name & Title

_____________________________________ ________________________________________
Name & Title Name & Title

_____________________________________ ________________________________________
Name & Title Name & Title

You and your child have protection under the procedural safeguards (rights) of special education law. The
school district must provide you with a copy of your procedural safeguards once a year.

X You received a copy of your procedural safeguard rights in a brochure about parent and child rights earlier
this year. If you would like another copy of this brochure, please contact the district at the telephone
number above.

X A copy of the parent and child rights brochure is enclosed with this invitation.

In addition to district staff, you may also contact _________________________________ at
___________________if you have questions about your rights.

Sincerely,

Revised 10/13/06
Melanie Facinger – LEA
School Psychologist

EVALUATION REPORT AND IEP COVER SHEET
Form I-3 (Rev. 10/06)

Name of Student DOB Sex Grade
Scott Liebscher June 7, 2009 Male 1st

Parent or Legal Guardian Telephone (area/number)
Sherri Liebscher 414-555-0550

District of Residence Current District of Placement Race/Ethnic (if parent chooses to
Milwaukee, WI Milwaukee, WI identify)

Address For students transferring between public agencies:
IEP reviewed and adopted by ________________________________________________
On _____________________________________________

For students transferring between public agencies:
Evaluation report reviewed and adopted by _____________________________________
On _____________________________________________

PURPOSE OF MEETING (Check all that apply):

X Evaluation including determination of eligibility X Initial or annual IEP development

□ IEP review/revision □ Develop a statement of transition goals and
services (required for students age 14 and older, or
younger if appropriate)
□ Placement □ Manifestation determination

□ Alternate assessment □ Determine setting for services during
disciplinary change in placement

□ Other: _____________________________ □ Other: _____________________________

If a purpose of this meeting is IEP development, review, and/or revision related to the academic, developmental
and functional needs of the child, the IEP team considered the results of:

Initial or most recent evaluation X Yes □ Not applicable
Statewide assessments □ Yes □ Not applicable
District­wide assessments □   Yes □ Not applicable
Date of Meeting: 05/07/2016

IEP Team Participants Attending or Participating by Alternate Means in the Meeting:
Parent/Guardian Regular education teacher/title Regular education teacher/title:
Sherri Liebscher Leanne Bishop

Revised 10/13/06
Student (if appropriate): Special education teacher/title: Special education teacher/title:
Trinette Paige
LEA Representative/Title: Other: Other:
Melanie Facinger/ Psychologist

Other: Other: Other:

If the parent did not attend or participate in the meeting by other means and did not agree to the time and place of the IEP
team meeting, document 3 efforts to involve the parents:

INDIVIDUALIZED EDUCATION PROGRAM: PRESENT LEVEL

OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Form I-4 (Rev. 9/13)

Name of Student: Scott Liebscher
Describe the student’s strengths and the concerns of the parents about the student’s education.
Scott’s strengths include ability to maintain attention, up to 7 minutes, when engaged in topic of his
interest, his nonverbal ability score on the Weschler Intelligence Scale for Children III was 111 putting
him in the 77th percentile. Scott scored above average on the Peabody Individual Achievement Test on 5
of the 6 Sub Tests. Scott’s parents’ concerns include: Scott’s refusal to engage in leisure activities such as
drawing, cutting, coloring, or repeating nursery rhymes; his defiance and tantrums which include yelling,
screaming, and throwing objects, with the inability to regulate emotions for up to two hours.

Describe the student’s present level of academic achievement and functional performance including how the
student’s disability affects his or her involvement and progress in the general education curriculum. For
preschool children, describe how the disability affects involvement in age-appropriate activities. (Note: Present
level of performance must include information that corresponds with each annual goal)

Scott has the ability to identify upper and lower case letters in the alphabet, identify pictures for words
beginning with; a, b, c, d, f, g, h, l, m, n, s, and t, retell a three-event story and answer comprehension
questions, count to thirty orally, identify basic shapes, recite the days of the week, and answer addition
and subtraction facts to 5. While Scott enjoys being in the regular education classroom, and possesses the
ability to learn the curriculum, his social skills and difficulty with emotional regulation impede his
classroom adjustment.

Will the student be involved full-time in the general education curriculum or, for preschoolers, in age-
appropriate activities? X Yes □ No
(If no, describe the extent to which the student will not be involved full-time in the general curriculum or,
for preschoolers, in age-appropriate activities)
Revised 10/13/06
SPECIAL FACTORS After consideration for special factors (behavior, limited English proficiency, Braille
needs, communication needs including deaf/hard of hearing, and assistive technology), is there a need in any of
the areas?
□ Yes X No (If yes or student has a visual impairment, attach I-5, “Special Factors” page)

INDIVIDUALIZED EDUCATION PROGRAM:

ANNUAL GOAL
Form I-6 (Rev. 10/06)

Name of Student Scott Liebscher

Measurable annual academic or functional goal to enable the student to be involved in and progress in the
general education curriculum, and to meet other educational needs that result from the student’s disability.
(Note: present levels of academic achievement and functional performance must include information that
corresponds with each annual goal)
Upon review: □ Goal met □ Goal not met

Currently aggressive reactions are less than 5 times per day, Scott will decrease aggressive reactions to 1-2
times per day. Aggressive reactions include kicking, spitting, hitting, throwing objects, yelling, and
threatening others.

Currently, Scott is able to verbally request his beanbag chair and talk through situations with staff, 50%
of 9 possible opportunities; Scott will talk through situations with staff and remain in seat 4 out of 9
possible opportunities, with continued access to the beanbag chair.

Currently, Scott refuses to participate in teacher directed and center based morning activities; Scott will
engage in teacher directed and center based morning activity 90 out of 120 minutes.

Procedures for measuring the student’s progress toward meeting the annual goal.
The teachers, including regular and special education, will collect data on Scott’s engagement in morning
activities, regulation of aggressive behavior, and ability to remain in seat during moments of frustration
and anger.

Will the student participate in an alternate assessment aligned with alternate achievement standards for students
with disabilities in any subject area? □ Yes X No
Revised 10/13/06
(If yes, include benchmarks or short-term objectives for the student)

When will reports about the student’s progress toward meeting the annual goal be provided to parents?

Parents will be notified of Scott’s progress toward meeting of annual goals at 9-week marking periods.

Revised 10/13/06
INDIVIDUALIZED EDUCATION PROGRAM: To be completed for students participating in
PARTICIPATION IN STATEWIDE ASSESSMENTS statewide and/ or district-wide assessments
Form I-7 (Rev. 11/07)

Name of Student: Scott Liebscher
 The student will be in (circle) 3d, or 4th, or 5th, or 6th, or 7th, or 8th, or 10th grade when the Wisconsin
Knowledge and Concepts Examination-Criteria Reference Test (WKCE-CRT) is given.
Check only one of the two boxes below.
 The student will be taking the WKCE for all content areas required at this grade level.
For students taking the WKCE, complete the assessment and accommodations grid below. Document the
accommodations, if any, needed for each of the content areas for students taking the WKCE.
OR
 The student will be taking the WAA-SwD for all content areas required at this grade level.
If yes, the Wisconsin Alternate Assessment (WAA) Participation Checklist is included with the IEP. For
students taking the WAA-SwD document the accommodations, if any, needed for the alternate assessment.

Student will WKCE WKCE WAA-SwD
participate in without with accommodations (list (list accommodations for each
the: accommo- accommodations for each content area)
dations in content area)
the content
areas of:
Reading Accommodations: Accommodations:

Math Accommodations: Accommodations:

Science Accommodations: Accommodations:

Language Accommodations:
Arts

Social Accommodations:
Studies

* The attached WAA participation checklist describes why the student cannot participate in the regular assessment and why
the alternate assessment is appropriate.

PARTICIPATION IN DISTRICT-WIDE ASSESSMENTS
X District-wide assessments given  District-wide assessments not given
 Student will not be in the grade when a district-wide assessment is given
List district-wide assessment(s) student will take:
Phonological Awareness Literacy Screening (PALS)

Describe appropriate testing accommodations, if any:
Extended Time. Small Group Setting. Frequent Break

Alternate Assessment – If the student does not take the regular district-wide assessment, describe why the
student cannot participate in the regular assessment and an alternate district-wide assessment is appropriate.
Revised 10/13/06
Revised 10/13/06
INDIVIDUALIZED EDUCATION PROGRAM:
PROGRAM SUMMARY
Form I-9 (Rev. 10/06)

Name of Student: Scott Liebscher

Projected beginning and ending date(s) of IEP services & modifications May 7, 2016 to May 6, 2017

Physical education: X Regular □ Specially designed
Vocational education: X Regular □ Specially designed
Include a statement for each of I, II, III and IV below to allow the student (1) to advance appropriately toward
attaining the annual goals; (2) to be involved and progress in the general education curriculum; (3) to be
educated and participate with other students with and without disabilities to the extent appropriate, and (4) to
participate in extracurricular and other nonacademic activities. Include frequency, location, & duration (if
different from IEP beginning and ending dates).
I. Special education Frequency/ Location Duration
Special education teacher will provide support Amount Regular 30 minutes
within the regular education classroom by assisting 3 times Education
Scott with morning activities, regulation of weekly Classroom
emotions, and decreasing aggressive behavior.

II. Related services needed to benefit from special education including frequency, location, and
duration (if different from IEP beginning and ending dates).

□ None needed to benefit from special education
Freq / Amt Location Duration
□ Assistive Technology
□ Audiology
□ Counseling
□ Educational Interpreting
□ Medical Services for Diagnosis and Evaluation
□ Occupational Therapy
□ Orientation and Mobility (VI only)
□ Physical Therapy
□ Psychological Services
□ Recreation
□ Rehabilitation Counseling Services
□ School Health Services
□ School Nurse Services
X School Social Work Services 2 times Office 15 minutes
Revised 10/13/06
weekly
□ Speech / Language
□ Transportation
□ Other: specify

Revised 10/13/06
Form I-9

III. Supplementary aids and services: aids, Freq / Amt Location Duration
services, and other supports provided to or
on behalf of the student in regular education
or other educational settings.
□ Yes X No (If yes, describe)

IV. Program modifications or supports for
school personnel that will be provided.
□ Yes X No (If yes, describe)

I-9 (2) Revised 10/13/06
Form I-9 Page ____ of ____

V. Participation in Regular Education Classes

X The student will participate full-time with non-disabled peers in regular education
classes, or for preschoolers, in age-appropriate settings.

□ The student will not participate full-time with non-disabled peers in regular
education classes, or for preschoolers, in age-appropriate settings. (If you have
indicated a location other than regular education classes or age-appropriate settings in the
case of a preschooler in I, II, or III above, you must check this box and explain why full-
time participation with non-disabled peers is not appropriate.)

VI. Participation in Extracurricular and Nonacademic Activities

Will the student be able to participate in extracurricular and nonacademic activities with
nondisabled students? X Yes □ No
(If yes, include under I., II., III., and IV. any special education, related services, supplementary
aids and services, and program modifications or supports necessary to assist the student. If no,
describe the extent to which the student will not be involved in extracurricular and nonacademic
activities with nondisabled students)
Form I-9 Page ____ of ____