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CONSIDERATION OF NEED FOR RESIDENTIAL TREATMENT SERVICES PSYCHOLOGICAL
ASSESSMENT REPORT
Sonoma County SELPA
To be completed by School Psychologist
Student Name:
D.O.B.:
Age:
School:
Grade:
Sex: Male Female
Case Manager:
Date(s) of Assessment:
Parent(s) Name(s):
Special Education Eligibility:
Address:
(Street & Number, City, Zip)
Phone: Home:
Work:
Cell:
Primary Language:
English Level: English only Initially /Fluent English/ Proficient/;
English Learner – Beginning/ Early Intermediate/ Intermediate/ Early Advanced/ Advanced/ Reclassified Fully English Proficient.
REASON FOR REFERRAL:
IEP team requested assessment to determine need for Residential Treatment Services.
A student who would be considered for Residential Treatment Services has behaviors that are:
 Resulting in significant A ongoing difficulties in educational performance due to
social/emotional issues (and/or)
 Presenting frequent, ongoing safety risks at school to self and/or others (and)
 Not sufficiently responsive to extensive supports and services which have been
provided at school and/or home as appropriate to address educational needs (and)
 Requiring and likely to benefit from a 24 hour a day, seven days a week
comprehensive therapeutic setting in order to access their educational services.
ASSESSMENT RESULTS:
The following report was developed to assist the IEP Team in determining need for residential treatment placement and related
services according Sections 300.304 to 300.306. The decision as to whether or not the assessment results demonstrate the need
for residential placement and related services as an offer of FAPE shall be made by the IEP Team. The IEP team shall take into
account all relevant material, which is available on the student. (From CC 5 Sec. 3030)
Materials and procedures were provided in the student’s native language/mode of communication in a form most likely to yield
accurate information on what the child knows and can do academically, developmentally, and functionally.
Assessment(s) were administered in English or in the student’s home language.
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A. BACKGROUND INFORMATION RELEVANT TO THIS REPORT:
1. Environmental, cultural, and economic information:
2. Health and developmental information:
3. Educational history:
Attendance history – (Describe any truancies, absences, or suspensions which may be related to social/emotional issues.)
Other relevant educational history – (Describe any social/emotional and/or behavioral services student has received.)
B. PREVIOUS ASSESSMENT INFORMATION:
SOURCES OF DATA REVIEWED: (check or indicate “NA”)
☐ Cumulative records
☐ Statewide Testing and Reporting results (STAR program)
☐ Progress towards goals
☐ Other data sources
Existing psycho-educational reports: (within three years list below)
Date
Type
Assessor
☐ Student survey/interview
☐ Parent survey/interview
☐ Teacher survey/interviews
C. NEW ASSESSMENTS ADMINISTERED (if any):
1.
2.
3.
D. RESULTS:
DISCUSSION AND RECOMMENDATIONS:
Signature: ______________________
Title: _____________________
Date: __________
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