Secondary Special Education and Speech Only ALE Referral by 1975g26Y


									                                         North Little Rock School District
                                 Referral for Alternative Learning Environment
                             Secondary (Special Education and Speech Only Students)

Section I       K-12 Special Education including Speech Only Identified Students
                Send to Diedra Gaskalla, Administrative Annex 771-8043

Section II
Today’s Date ______________________
Name _____________________________________________________ ID # _______________
DOB _____________________ Age _____ Race ______ Gender _____ SS#____________________________
Current School ___________________________________ Grade _______________# of Credits___________
Referring Person & Title ________________________________________________________
Parent _____________________________________ Address _____________________________________
Phone Numbers: Home ____________________ Cell ___________________OTHER___________________

Section III
Are any outside agencies involved with this student? (Check one)

Is the student currently taking medication? ________ If yes, list___________________________

If not on medication, has the student been on medication in the past? _____________________

Disability__________________Date of last evaluation_______________

Date Behavior Intervention Plan was written or reviewed___________________________

Are behavior goals included in the current IEP?___________________________

Section IV
Referral Reason:
An eligible ALE student shall exhibit two (2) or more of the characteristics identified in and (ADE Rules). Students will not be
placed in an Alternative Learning Environment based on academic or truancy problems alone. Students placed at risk, though intelligent and
capable, typically manifest one or more of the following characteristics:

   Disruptive behavior
   Recurring absenteeism/ Drop out from school
   Transition to or from day treatment/residential programs
   Personal or family problems or situations
   Abuse: physical, mental, sexual (attach to referral documentation of abuse)
   Frequent relocation of residency (attach documentation)
   Homelessness (Contact Bobby Riggins prior to referral)
   Inadequate emotional support (please explain) __________________________________________________________
   Mental/physical health problems (documentation from school nurse required)
   Pregnancy
   Student is a parent
   Other (please explain) ___________________________________________________________

Section V
 Referral narrative forms (3 narratives required: principal, assistant principal, teacher(s), nurse, and/or counselor)
 Attendance printout
 Current grades/Transcript
 Discipline summary
 Truancy Referral Form, if truancy is a referral factor
 Sending School Referral Conference Form Signature Sheet, STAMPS ARE NOT ACCEPTABLE
 Current IEP
 FBA (If student has been suspended more than 10 days out of school)
                                        North Little Rock School District
                                                Referral Narrative

Student’s Name _____________________________________________________
Person Completing Form & Title ___________________________________________________
Date ______________________

Referral Reason:
List the presenting problems that are prompting the referral to an alternative learning program. Provide a narrative
that describes the behaviors that are impeding academic progress. Be as specific as possible, giving examples and
frequency of presenting behaviors. **Do not attach behavior documents or discipline referrals.

                 Sending School Referral Conference Form
                                  Signature Sheet

Student Name: __________________________ Date: _________________

Minimum Required

      Name                                               Title

___________________________                              Referring Administrator

___________________________                              Counselor

___________________________                              Teacher

___________________________                              ____________________

___________________________                              ____________________

___________________________                              ____________________

I understand my child has been referred to an “Alternative Learning Environment”
(ALE) in the North Little Rock School District. Students will remain in their current
school until placement has been determined.

I agree with this referral: ___       I do not agree with this referral: ___

Parent/Guardian Signature: ___________________________________

Building Principal’s Signature: __________________________________
                                      ALE Referral
                              For all Special Ed. Students
                            Including Speech Only Students

                      Needed items in addition to a current IEP

For students exhibiting behavior problems and needing an ALE referral, a Separate
Programming Conference (SPC) must be held first. The conference should include:
Parent, School Administrator, Speech Pathologist, Counselor, Teacher, Mental Health
Professional, and any other applicable person(s).

If a Behavior Intervention Plan (BIP) has not been written:
     Document behavior concerns on SPC decision form
     Develop a behavior plan
     If a student has been suspended for more than 10 days for the current school
      year , a Functional Behavior Assessment (FBA) must also be completed
    Implement the behavior plan for more than two weeks documenting results
    ALE referral will be suspended at this time while data is collected on the BIP

If a   Behavior Intervention Plan (BIP) has been written:
       Insure behaviors on the BIP are the ones presently exhibited
       Document what is/isn’t working on the BIP
       If the BIP is working continue implementation suspend ALE referral
       If the BIP is not working (as evidenced by data collected such as: disciplinary
        referral, suspensions, and teacher documentation) submit this information with
        a completed ALE referral

 On Separate Programming Conference form do not write that an ALE placement is
recommended. Do write that an ALE referral packet will be completed and submitted.

When the ALE referral is submitted make sure to include the following items:
   ALE completed referral packet (can be found on the intranet under Teacher
     Resources heading)
   IEP
   Separate Programming Conference documentation ( including notices and BIP)
   FBA if suspended more than 10 days out of school

 At the beginning of a new school year (or with incoming transfer students- in or out
of district), an appropriate amount of time should be given for the student to become
familiar with the school environment before an ALE referral is considered.
(Recommended time frame is 6 weeks)

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