MULTIDISCIPLINARY/EVALUATION REPORT - CONFIDENTIAL
Student’s Name:
Date of Birth:
Chronological Age:
Parents’ Names:
Grade:
Teacher:
School:
Date of Report:
REASON FOR REFERRAL
ASSESSMENT PROCEDURES
Assessment
Review of Academic and Behavior Records
Date
Multiple
Educational Observations
Multiple
Kaufman Assessment Battery for Children, 2nd Edition (KABC-II)
5/31/13
Staff Member
School Psychologist
School Social Worker
School Psychologist
School Social Worker
School Psychologist
Medical Information Update
Vineland-II Adaptive Behavior Scales
Behavior Assessment System for Children-2nd Ed
Multiple
Multiple
School Psychologist
School Social Worker
BACKGROUND INFORMATION
School History-
PARENT INFORMATION
Parent Report -
TEACHER INTERVIEW
THERAPIST INPUT (5/8/13)
STUDENT INTERVIEWS (School Social Worker and School Psychologist)
School Staff Observation –
Multidisplinary Evaluation Report
Lastname, Firstname
BEHAVIOR SUPPORT PLANS
Behavior Plans and Behavioral Progress
Month
January
Februar
y
March
April
May
Aggression /
Week For Month
0
Disrepect / Week
for Month
0.5
Leave Area /
Week for Month
1
Total Behaviors /
Week for Month
1.5
0.5
0.25
0.25
2
0
0.75
2
1.5
0.5
0
0
0
0
1.5
1.25
2
Aggression / Week For Month
Behavior Chart
Disrepect / Week for Month
Leave Area / Week for Month
Behaviors / Week For Month
2.5Total Behaviors / Week for Month
Linear (Aggression / Week For Month)
2
1.5
1
0.5
0
-0.5
:
Antecedents
Behaviors
Consequences
FUNCTIONAL BEHAVIOR ANALYSIS DATA
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2
Multidisplinary Evaluation Report
Lastname, Firstname
The context in which the behaviors were most likely to occur was Recess/lunch, as his behaviors
occurred 37% of the time during this setting. The next most likely setting was specials, where is
behaviors occurred 16% of the time.
The antecedent (or trigger) that occurred primarily before the behaviors were most likely to be
transitions, as this was the recorded antecedent 32% of his recorded behaviors. The next two most
likely antecedents (21% of his recorded behaviors) were when student was given an instruction or
directive, and when he was given a choice.
The staff action that occurred after his recorded behaviors was that student was given a choice, as
this action occurred after 63% of student’s recorded behaviors. The staff action of giving student a
choice was also recorded to be the most successful action at stopping student’s recorded behaviors.
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Multidisplinary Evaluation Report
Lastname, Firstname
OBSERVATIONS (School Psychologist)
OBSERVATION (School Social Worker)
ASSESSMENT OF COGNITIVE ABILITIES
Test Description– The Kaufman Assessment Battery for Children, 2nd Edition (KABC-II) is an
individually administered measure of the processing and cognitive abilities of children and
adolescents aged three through eighteen. The KABC-II Fluid-Crystallized Index (FCI) global score
is designed to represent an overall measure of cognitive ability. The FCI is comprised of four scales
for 5 year; Sequential, Simultaneous, Learning, and Knowledge. The Sequential scale is comprised
of Number Recall and Word Order subtests. The Planning scale is comprised of Story Completion
and Pattern Reasoning subtests. The Learning scale is comprised of the Atlantis and Rebus
subtests. The Simultaneous scale was comprised of the Conceptual Thinking, Rover, and Pattern
Reasoning subtests. Finally, the Knowledge scale is comprise of the Verbal Knowledge and
Riddles subtests.
Test Behavior ––
Current Levels of Performance –
Cognitive Processing Strengths and Weaknesses –
ASSESSMENT OF ADAPTIVE BEHAVIOR
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Multidisplinary Evaluation Report
Lastname, Firstname
Test Description –
Current Levels of Performance –
BEHAVIOR ASSESSMENT SYSTEM FOR CHILDREN 2nd EDITION (BASC-2)
The Behavior Assessment System for Children, Second Edition (BASC-2) is an integrated system
designed to facilitate the differential diagnosis and classification of a variety of emotional and
behavioral disorders of children and to aid in the design of treatment plans. This computergenerated report should not be the sole basis for making important diagnostic or treatment
decisions.
EMOTIONAL IMPAIRMENT CRITERIA AND CONSOLIDATED EVALUATOR DATA
Emotional Impairment Eligibility Criteria
Criteria Evidence for this Conclusion
Met
(Data that supports criteria decision)
Emotional Impairment Eligibility Criteria
Y
(1) Over an extended period, this student has
(1)
manifested problems primarily in the affective
domain to the extent that he/she cannot benefit
Y
from learning experiences without special
education support.
(2) The problems are characterized by one or
more of the following behaviors:
a. Inability to build or maintain satisfactory a. N
interpersonal relationships within the
school environment.
b. Y
b. Inappropriate types of behavior or feelings
under normal circumstances.
c. Y
c. General pervasive mood of unhappiness or
depression.
d. Y
d. Tendency to develop physical symptoms
or fears associated with personal or school
problems.
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a.
b
c.
d.
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Multidisplinary Evaluation Report
Lastname, Firstname
(3) Emotional impairment also includes
students who, in addition to the characteristics
specified in subrule (1) of this rule, exhibit
maladaptive
behaviors
related
to
schizophrenia or similar disorders. The term
"emotional impairment" does not include
persons who are socially maladjusted, unless it
is determined that the persons have an
emotional impairment. Are the student’s
difficulties
due
primarily
emotional
impairment rather than social maladjustment?
(4) Are the student’s problems primarily the
result of intellectual, sensory, or health
factors?
(5) When evaluating a student suspected of
having an emotional impairment, the
multidisciplinary evaluation team report shall
include documentation of all of the following:
a. Does the student’s difficulties extend
beyond the educational settings?
b. Does systematic observation of the
behaviors of primary concern indicate that
the behaviors interfere with educational
and social need?
c. Have intervention strategies been used to
improve the behaviors? If yes, document
how long.
d. Has relevant medical information been
documented?
Report Parent Input
Report Current Levels of Y/N
Educational
Functioning/Educational
Needs
(3)
(3) Y
(4)
(4) Y/N
a.
b.
a. Y/N
c.
d.
b. Y/N
c. Y/N
d. Y/N
POSSIBLE INTERVENTION STRATEGIES:

School social work services (etc.)

The use of social narratives to teach student self-regulation and coping strategies and prep
for in-class activities may be an effective resource.
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Multidisplinary Evaluation Report
Lastname, Firstname
RECOMMENDATIONS:
Student meets the criteria for special education services under the category of Emotionally
Impaired. However, the IEP team which includes the parents, will make the final eligibility
determination.
___________________________
Brian Lloyd Ed.S., NCSP
School Psychologist
___________________________
School Social Worker
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