Referral Checklist for Emotional Disturbance
Student’s Name ____________________________
Date sent to psych services* __________________
_____ Parent Input Form
_____ SST Meeting Summary & Intervention Plan
_____ SST Behavioral Supports Form
_____ FBA Report
_____ Behavior Intervention Plan
_____ SST Follow-up Meeting Summary (if applicable)
_____ Student Support and Interventions Team Referral for Comprehensive Evaluation
_____ Permission to test with Prior Written Notice
_____ General Education Teacher’s Input Form
_____ Direct observation #1 by a licensed professional; cannot be completed by the same person that
provided the General Education Teacher’s Input Form
_____ Direct observation #2 by a third licensed professional in a different setting and at a different time
_____ Medical Information Form completed within the past year (to rule out physical conditions as the
primary cause of atypical behavior)
_____ Behavior Assessment System for Children, Second Edition (BASC-2) Teacher Rating
_____ Behavior Assessment System for Children, Second Edition (BASC-2) Parent Rating
_____ Behavior Evaluation Scale-Third Edition School Version (BES-3:L SV)
*(Please do not send the referral file to psych services until all information has been gathered and
included in the referral folder.)