Barren County Schools
District Autism Team
Request for Assistance Form
Teacher Name:
Student Name:
Medical Diagnosis/es:
School:
IEP?: Yes/No
Grade:
Disability:
I. What are your areas of concern?
Social
_____Difficulty recognizing others' feelings
_____Does not maintain personal space
_____Struggles with taking turns
_____Inappropriate (or limited) interaction with peers
_____Refuses to join group activities
Other:__________________________________________________________
Behavior
_____Difficulty with change (routine, transitions, etc)
_____Demonstrates obsessive tendencies
_____Demonstrates repetitive movements
_____Difficulty transitioning from preferred activity
_____Preoccupied with unique interests
Other:___________________________________________________________
Communication
_____Repeats words/phrases spoken by others
_____Asks repetitive questions
_____Limited means of communicating (speech, gestures, etc.)
_____Easily frustrated when attempting to communicate
_____Difficulty asking and answering questions
_____Does not follow simple directives
_____Does not respond to name
Other:___________________________________________________________
Sensory
_____Unusual response to noises, smells, foods, textures, touch (circle)
_____Demonstrates sensory seeking behaviors (movement, touch, pressure)
_____Inappropriate sensory exploration (licking, putting things in smell, smelling)
_____Makes unusual noises at inappropriate times
Other:___________________________________________________________
Cognitive
_____ Demonstrates academic weaknesses
_____ Difficulty applying learned skills in new settings
_____ Difficulty retaining learned information
_____ Attention problems
_____ Lack of organization
Other ______________________________________________________
Motor
______ Poor handwriting
______ Poor coordination
______ Atypical activity level (hyperactive, lethargic)
Other ______________________________
Emotional
_______ Anxious or easily stressed/frustrated
_______ Unusual fear responses (overly fearful or little to no fear)
_______ Exhibits rage reactions or melt downs
_______ Injures self or others
_______ Depressed or sad
Other ________________________________________
II. What have you tried to resolve the problem areas?
Academic Support (IEP/RTI)
Reinforcement System
Visits with School Counselor
Conferencing with Parents
First-Then Board
Office Referrals
Other:
Visual Supports/Schedule
Daily Points Sheet
Peer Buddy
Social Stories
Classroom Positioning
Loss of Privileges
III. What are the student’s strengths?
IV. What else should we know about this student?
V. What are you hoping to gain/accomplish from Autism Team assistance?