Psychological Services Forms

Last Updated: 4/27/2022 9:23 PM

Student Assistance Team Manual 
Updated 3/9/2022


504 Forms

504 Consent Form (Word) (PDF)
504 Meeting Invitation Form (Word) (PDF)
504 Memorandum of Conference (Word) (PDF)
504 Pamphlet (Word) (PDF)
504 Parent and Student Rights (Word) (PDF)
504 Prior Written Notice for Student (Word) (PDF)
504 Parent Questionnaire (Word) (PDF)
504 Student Accommodation Plan (Word) (PDF)
504 Student Eligibility Form (Word) (PDF)
504 Termination Report (Word) (PDF)
504 Testing Accommodations: updated 3/25/2022 - (PDF)
Disciplinary Action Review Form (Word) (PDF)
Verification of Dissemination of 504 Plan (Word) (PDF)  
504 Complaint Form (Word) (PDF)
504 Distance Learning Plans (Word) (PDF)
504 Documentation of Parent Communication (Word) (PDF)
504 Monthly Planning (Word) (PDF)
504 Reminder Checklist (Word) (PDF)

Alternative Education Forms

Alternative Ed Referral Flow Chart (Word) (PDF)
Alternative Placement Checklist for Administrators (Word) (PDF)
Alternative Ed Referral Packet - All Forms (Word) (PDF)
GUIDES Overview and Checklist (Word) (PDF)




Behavior Assessment Forms

Behavior Observation Form (Word) (PDF)
Forced Choice Reinforcement Survey (Word) (PDF)
FBA Manual (Word) (PDF)
FBA Parent Interview (Word) (PDF)
FBA Team Responsibilities Form (Word) (PDF)
FBA Worksheet (Word) (PDF) Print and Hand Write (Word) (PDF)
Initial Line Explanation (PDF)
Initial Line of Inquiry Chart (Word) (PDF)
Teacher Input Questionnaire (Word) (PDF)
Problem Behavior Questionnaire (PDF)
Student Functional Interview (PDF)
Teacher Data Collection Form (Word) (PDF)

Multi-Tiered System of Supports (MTSS)

MTSS Fidelity Checklist (Word) (PDF)
MTSS Math Chronology Checklist (Word) (PDF)
MTSS Reading Chronology Checklist (Word) (PDF)

MTSS Behavior Intervention Worksheet (Word) (PDF)


Preschool Student Assistance Team Forms

Referral Form (Word) (PDF)
Preschool SAT Report (Word) (PDF)
Teacher Evaluation Form (Word) (PDF)

Student Assistance Team Evaluation Reportsused to document results of SAT level evaluations

Academic Diagnostic Report for KBIT and KTEA (Word) (PDF)
Conners 3 (Short Form) SAT Report (Word) (PDF)
CTOPP-2 Ages 4-6 SAT Evaluation Report (Word) (PDF)
CTOPP-2 Ages 7-24 SAT Evaluation Report (Word) (PDF)
GORT-5 SAT Eval Report (Word) (PDF)

Student Assistance Team Meeting Forms

SAT Meeting Notice (Word) (PDF) Spanish (Word) (PDF)
Consent for SAT Evaluations (Word) (PDF)
SAT Assignment Form (Word) (PDF)
SAT Data Required Form (Word) (PDF)
SAT Page 1 (Word) (PDF)
SAT Page 2 (Word) (PDF)
Verification of Dissemination of SAT Plan (Word) (PDF)

Student Assistance Team Referral Forms

SAT Reminders Document (Word) (PDF)
SAT Referral Checklist (Attach to SAT Referral Form) (Word) (PDF)
SAT Referral Form (Word) (PDF)

Crisis Response Documentation

Restraint Use Documentation (PDF)
Crisis Team Documentation without Restraint (Word) (PDF)

Additional Forms

Consent to Release and Obtain Information (Word) (PDF)

Special Education Forms

Special Education Process Forms with Instructions (PDF)

Forms needed for Initial Evaluations/Reevaluations/Additional Evaluations through IEP

Parent Questionnaire for Gifted (Word) (PDF)
Gifted Special Consideration Checklist (Word) (PDF)
Multi-Disciplinary Team Tracking Form (Word) (PDF)
Notice of Individual Evaluation/Reevaluation Request (PDF)
Observation Report (Word) (PDF) - completed if requested on consent form
Parent Information Form for Special Education (Word) (PDF)
Prior Written Notice (PDF)
Teacher Evaluation Form (Word) (PDF)
Reevaluation Determination Plan (Word) (PDF)
Reevaluation Meeting Notice (PDF)
Request Additional Evaluations Through IEP (PDF)

Eligibility Committee Meeting Forms

Eligibility Committee Report (PDF)
Eligibility Committee Meeting Notice (PDF)
Prior Written Notice (PDF)
Specific Learning Disability Team Report (PDF)
Speech/Language Impairment Team Report (PDF)
Autism Team Report (PDF)

Medicaid Forms

Medicaid Consent to Release and Bill (PDF)
Medicaid Physician Authorization Form (PDF)
Medicaid Service Care Plan (PDF)
Notice to Parents Parental Consent to Access Public Benefits or Insurance (PDF)

Motor Team

Educational vs Medical Model