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5430.1-R, Procedure for Psychological Referral

  1. Consideration for referral should be given a child who evidences any of the following characteristics: severe academic or learning deficits, emotional problems, adjustment problems, or other significantly inappropriate behavior.
  2. For the psychologist to see a child, the standard psychological referral form should be completed. The statement of concern should be clearly stated on this form. Included with the statement of concern, the teacher should indicate the expected outcomes of the referral. Also included should be those procedures and techniques which have already been used with the child.
  3. The completed referral form should be given to the building principal at the elementary level or to the student’s counselor at the secondary level. When a formal psychological evaluation is indicated, written parental consent should be attached to the referral form.
  4. Each building principal and/or PST chairperson should maintain a supply of appropriate referral forms, parent consent forms and release of information forms.
  5. Responses to psychological referrals will be made on the basis of urgency, time constraints and date of referral. When the number of referrals exceeds the school psychologist’s time in the building, the building principal and school psychologist will make a determination as to the referrals having highest priority.
  6. After the referral has been acted upon by the school psychologist, the referral form, the parent consent form and the written recommendations resulting from the referral should be filed in the student’s special education file if he/she is disabled. If the student is not disabled, the consent and referral forms are placed in the student’s cumulative file. Protocols and related diagnostic recommendations are placed in a file stored in the school psychologist’s office.

June 21, 1999