St.

Kevins
Junior High

Assessment
Referral
Booklet

Purpose
The following booklet is a step by step guide, designed for
staff at St. Kevins Junior High which will bring you through
the process of what to do when you notice an issue with a
student and how to make a referral for assessment to the
Service Delivery Team.
Please note that referrals can be made either when
students are:

1. Struggling with the curriculum and it is too

challenging.
Or
2. When students are excelling beyond the curriculum
and it is not challenging enough.

Forms that you need to complete to make a referral are

included in this booklet. Please complete the forms
digitally, save a copy and print and sign to submit to the
team.
**NOTE: To open any of these forms hold CTRL and click on
it **
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Step 1:
You notice an issue with a
student
1. Inform the Parents
2. Check the students cumulative and support files
(located in the office).
3. See if any interventions have been recorded in the
cumulative record which have been tried and found
successful.
4. Consult the PRIM (pre-referral intervention
manual).
*** The PRIM is a reference guide which lists 219
possible difficulties a student may have and many
classroom techniques which may help a student
overcome these difficulties.
***A copy of the table of contents for the manual
is included in the following pages of this booklet.
From this table of contents, find the issue which
best suits what you have noticed with your
student.
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5. A copy of the PRIM can be found in the staff room on

the Service Delivery Team Bulletin Board. Please sign
it out when you are using it so others know where to
find it.

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Step 2:
The Record of Pre-Referral
Strategies
*** The Record of Pre-referral Strategies summarizes a students
strengths and needs. It highlights the issues a teacher has noticed
with a student and the classroom interventions a teacher has tried, in
order to help a student, prior to referral for assessment. The purpose
of this form is to allow assessors to get a better picture of the student
as a whole and what interventions have been tried in order to make
more informed suggestions around further recommendations.
Prior to completing the Record of Pre-referral Strategies, discuss with
students and contact the parents/guardians of the student to make
them aware of the process and the interventions you are trying with
their child. Explain that after a period of trial with the interventions,
you will share with them the results and make a referral for
assessment if required.
PLEASE NOTE: The Record of Pre-referral Strategies should always be
completed weather a referral is followed through or not, as this can be
used by future teachers.
A copy of the Record of Pre-referral Strategies form follows on the
next page. To complete the form:
1. Go to the electronic version of the form by holding Ctrl and
clicking the image of the form on the following page of this
booklet.
2. Complete the personal information section.
3. List strengths and needs you have noticed with this student in
the table provided.
4. Make note of interventions you have already tried with this
student, in the space provided along with the approximate date.
5. Choose other interventions from the PRIM which you will try with
the student and record this in the space provided along with the
approximate date.
*** It is recommended that you complete a digital copy of the
record of pre-referral strategies as this will insure a copy
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remains in the unlikely yet unfortunate event of fire or

destruction of records. As well, in the electronic version the
tables and typing space will expand according to what you
type, which is rather restricted in the print version.

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Step 3:
Implement and Observe
these interventions
1. Over a period of time observe the success of these
interventions. Have they helped the student with the
difficulties you have noticed?
2. Record your observations and the effect of these
interventions on the Record of Pre-referral Strategies
form.
3. Have the parent/guardian sign the Record of Prereferral Strategies form. To do so you may:
a) Call the parent and have them come in to review
and sign the form.
b)Call the parent and send the form home in an
envelope with the student to be signed.
*** If sending the form home with a student,
please make a copy first (in the event that the
student may misplace the form).
*** Please note that with the new criteria for
diagnosis for a Specific Learning Disorder
interventions must have been in place for a
period of at least 6 months.

Step 4:

Discuss these
interventions with an
Instructional Resource
Teacher
If the intervention has been successful:
1. Review with an instructional resource teacher as to
whether the intervention will require a documented
exceptionality to be continued and weather to
continue with a referral.
2. Place a copy of the Record of Pre-referral Strategies
form in the students service delivery file (red folder
found in the cumulative files in the main office).
If the intervention is not successful:
1. Speak with an instructional resource teacher to
inform them of your trial and that you will continue
with a referral for this student.
***Reviewing with an instructional resource
teacher at this point is important to ensure
another referral is not currently in progress by
another teacher for this same reason.

Step 5:
Completing Hearing/Vision
Screen
1. Before beginning the referral paperwork, contact the
parent/guardian of the student to inform them of the
referral and request their consent.
2. Upon agreement from parents to continue the
referral, you will need to first have the students
hearing and vision screen completed to ensure there
is no issue which could be leading to their struggle.
3. Speak to the parents about the hearing and vision,
they may choose to see public health or their own
doctor themselves to have this completed (in which
case you will need to obtain a copy of the results and
submit with the referral paperwork) or have the
screen conducted by public health when they come
into the school.
4. If the screen is being completed by public health
here at the school, complete the top part of the
consent for hearing and vision screen, print and have
the parents sign (either by coming into the school or
by sending home with the student in a sealed
envelope).
*** The Consent for Hearing and Vision Form
cannot be completed electronically. Please print
and complete a paper by hand.

Step 6:
Submitting and Waiting on
Hearing and Vision
1. Once you have obtained signed consent for hearing
and vision, please submit this to Guidance or the
Main Office. Public Health will come in periodically
throughout the year and results will be released once
complete.
2. When you have received the results from hearing
and vision, you may proceed with the referral
depending on the result.
a) If no referral is recommended for either hearing or
vision, proceed with the referral by completing the
Referral to Service Delivery Team
b)If a referral is recommended for either the hearing
or vision, please follow up with the parent shortly
after to ensure they see their doctor and you
receive appropriate documentation before
proceeding with the referral.

Step 7:

Completing the Paperwork

Referral to Service Delivery Team Form
Once the students hearing and vision have been approved,
you may make the referral to the Service Delivery Team.
The Assessment Referral to Service Delivery Team form is a
quick summary of the student and the referral. It provides
relevant information on the student, the status of the
assessment and provides the reason for the referral.
To complete this form:
1. Fill in the personal information at the top of the page
using the information from Demographics on
PowerSchool.
2. DO NOT write in the Referral Tracking Number Box at
the Top.
3. Check with the Guidance Counsellor to find out if this is a
reassessment and if there is a previous RTS #.
4. Students will be on an IEP if they have any modified
courses or Alternate Programs or Alternate Courses.
5. Students will be on an ISSP if they have outside agencies
involved.
*** Check with an IR teacher if you are unsure
whether a student has an IEP or an ISSP.
6. CHECK off the Hearing and Vision Boxes only once you
have the passing results and attach with the referral.
7. Please complete the questions you would like answered
in detail.

Referral Tracking Number

Assessment Referral to
Service Delivery Team

D.

H. Y

R.

Entered by Student Support Services Teamat the SST Meeting

Name:

Gender:

Step 8:

D.O.B.: (yyyy/mm/dd)

MCP:

Parent/Guardian:
School: St. Kevins Junior High

School Telephone: (709) 745 8980

Teacher:

Grade:

Principal: Ms. Yvonne Barry

Guidance Counsellor: Ms. Deanna Miles

Submitting and Reviewing

Status
the Paperwork
If yes, please provide previous RTS#

Is this a Reassessment?
Reason for Reassessment:

No

Yes

D.

H. Y

R.

1. Once you have completed the Assessment Referral to

the Service Delivery Team, attach a copy of the
Prescribed Curriculum
Alternate Program
hearing and vision results and
review
before
Accommodations
Alternate
Course
Modified Prescribed
Alternate (Functional) Curriculum
submitting.

Indicate Current Programming(s): ( as many as apply):

Other Personnel Involved:

Yes
No
An ISSP?
Yes
2. Following submission
to the
Service
Delivery
Team, No
Hearing/Vision Check
the team will review the referral to ensure everything
Attach Most Recent Results:
Hearing
Vision
isfrom
complete
and
the referral should continue.
(Teacher obtains
parent/guardian or public
health)
Does the student have an IEP?

Referral Reason

3. Once reviewed, the team will inform you the referral

Academic
has Specify
been accepted or not. If a referral is not
Behaviour Specify
Social/Emotional
Specify
accepted
it usually means further information is
Speech Language Specify
required
before it can be accepted and they will go
Others
Specify
back
for it.
What questions
wouldto
you you
like answered
as a result of this referral?
What is the main area of concern?

Teacher Signature:

Referral date:

Authorized by the Department of Education

September 2010

Step 9:

What happens next?

1. Following submission to the Service Delivery Team, the team
will review the referral to ensure everything is complete and
the referral should continue.
2. Once reviewed, the team will complete the Referral to
Guidance Counsellor/Educational Psychologist (including
appropriate attachments) as needed and the Consent for
Assessment.
3. Once consent is obtained, the referral will be prioritized by
the Service Delivery Team, put on the list, registered into the
Referral Tracking System (RTS), and submitted to the
assessor.
*** Depending on the time of year, there may be other
referrals in place and their priority is determined based
on how long students have been on the list for an
assessment (including a list from another school).
4. Once the assessment is complete, the Assessor will discuss
results with the IR Teacher(s) and teachers, parents and
student involved to look at possible recommendations.
Assessor may meet privately with parent to review results in
certain circumstance.
5. A month after supports have been put in place, teachers,
parents, guardians, the student and team should discuss if
supports are proving helpful and should be continued or
need to be revised.

Checklist
The following checklist can be used to track your progress through a
referral and check off each of the tasks as you complete them.
Name: __________________________________ Grade: ________
Notice Issue with Student
Check the red Service Delivery File with the cumulative files in the
main office
Consult the PRIM (copy in the staff room Service Delivery Board)
Discuss with student and contact Parent/Guardian to inform
Complete the Record of Pre-referral Strategies Form
Observe and record effect of interventions
Have parent/guardian sign form
Discuss pre-referral with instructional resource teacher to see if to
continue with referral
Contact parent/guardian to inform of intention to continue with
referral
Complete consent for hearing and vision screening and have
signed by parents. (Make photocopy if sending home.)
Complete referral to Service Delivery Team
Review all paperwork prior to submission to Service Delivery
Team.
Discussion with assessor regarding results of assessment and
possible recommendations, if applicable.
Meeting with all teachers, parents/guardians and student to
decide supports to put in place.
Review after a month whether supports are successful and should
be continued.
Continued monitoring over the long-term as to whether supports
are successful and should be continued.