School COPE Referral Form (Christ the Redeemer) Community Outreach of Pediatrics and Psychiatry in Education

Date Filled Out

Student

Student Name

Preferred Name

Date of Birth

Gender

Grade

Special Education Code(s)

School

School Name

School Phone

School Fax

School Contact

Role

Person Completing Form

Parent/Legal Guardian #1

Name

Address

Postal Code

Work Phone

Home Phone

Cell Phone

Parent/Legal Guardian #2

Name

Address

Postal Code

Work Phone

Home Phone

Cell Phone

COPE offers consultations by pediatricians and child psychiatrists. Please specify the medical, mental health or socio-emotional questions or concerns that you have about your student.

Concern/question #1

Concern/question #2

Concern/question #3

Has this student had a Speech and Language Assessment?

If Yes, Age

Has this student had Psychoeducational Testing?

If Yes, Age

Has this student received any other assessments?

Has this student been given any diagnoses (e.g., Learning Disability, ADHD, Asthma…]?

If Yes, what

What school based services is this student currently receiving or on a wait list for?

Narrative Description of Child – Teacher (IRS)

Centre for Children & Families, University of Buffalo

Instructions: In the spaces below, please describe what you see as this child's primary problems in each area and describe the effects of this child's problems in that area over the past three months.

Then drag the slider towards the points that describe how much the child's problems affect each area and whether he or she needs treatment or special services for the problems (see sample below)

1. How this child’s problems affect his or her relationships with other children.

No Problem

Extreme Problem

2. How this child’s problems affect his or her relationship with the teacher.

No Problem

Extreme Problem

3. How this child's problems affect his or her academic progress.

No Problem

Extreme Problem

4. How this child's problems affect your classroom in general.

No Problem

Extreme Problem

5. How this child’s problems affect his or her self-esteem.

No Problem

Extreme Problem

6. Overall severity of this child’s problem in functioning and overall need for treatment.

No Problem

Extreme Problem

Has this student been removed from the classroom due to his/her behaviour in the last month?

Has this student had any special school placements previously (i.e. Behaviour class, Learning Support class]

If Yes, please list

Please describe any concerns about home life.

The MTA SNAP-IV Rating Scale

1. Fails to give close attention to details or makes careless mistakes in schoolwork or tasks

2. Has difficulty sustaining attention in tasks or play activities

3. Does not seem to listen when spoken to directly

4. Does not follow through on instructions and fails to finish schoolwork, chores or duties

5. Has difficulty organizing tasks and activities

6. Avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort

7. Loses things necessary for activities (e.g., toys, school assignments, pencils, or books]

8. Is distracted by extraneous stimuli

9. Is forgetful in daily activities

10. Has difficulty maintaining alertness, orienting to requests, or executing directions

11. Fidgets with hands or feet or squirms in seat

12. Leaves seat in classroom or in other situations where remaining seated is expected

13. Runs about or climbs excessively in situations in which it is inappropriate

14. Has difficulty playing or engaging in leisure activities quietly

15. Is "on the go" or often acts as if "driven by a motor"

16. Talks excessively

17. Blurts out answers before questions have been completed

18. Has difficulty awaiting turn

19. Interrupts or intrudes on others (e.g., butts into conversations or games]

20. Has difficulty sitting still, being quiet, or inhibiting impulses in the classroom or at home

21. Loses temper

22. Argues with adults

23. Actively defies or refuses adult requests or rules

24. Deliberately does things that annoy other people

25. Blames others for his or her mistakes or misbehaviour

26. Is touchy or easily annoyed by others

27. Is angry and resentful

28. Is spiteful or vindictive

29. Is quarrelsome

30. Is negative, defiant, disobedient, or hostile toward authority figures

Additional Comments

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