STUDENT SUPPORT PLAN

Pre-referral Planning Form

Student: XXXX XXXX
Age: 6 yrs

Difficulties and Concerns: (What are the difficulties and concerns associated with the student? What factors
appear to be contributing to the difficulties and concerns?)
Social Skills: Student needs to work on following directions and safety skills in the community. Student tends to
interact more with adults than peers. He needs adult support to take-turns, play board games an share with
peers.
Student generally chooses to do independent activities. He plays in proximity to peers but rarely initiates
interactions with them. He responds appropriately with prompting.
Communication: Student needs to increase the length and variety of utterances, question skills and his ability to
use language to interact more successfully in his environment.
Students length of utterance is highly dependent on his motivation by the task/activity. He often uses phrases
and modeled phrases to expand utterances Student uses intonation change to indicate he is asking a question
more often than question words. His abilty to answer simple questions about books is inconsistent. He indicates
yes or no to preference questions. It often takes multiple repetitions of a question or his name to gain Students
attention if he is focused on something else.
Motor: Students performance demonstrates a need for occupational therapy related services to address his fine
motor delays, sensory motor challenges and weak hand strength. And, a need for physical therapy related
services to address his delayed gross motor skills.
Student demonstrates definite sensory processing problems that are interfering with his ability to participate in
class. His scores indicate a low threshold for stimuli and an active strategy to keep sensory input away. Data
shows Student frequently avoids eye contact, stands or sits at the side of the playground during recess,
withdraws from activities, is stubborn or uncooperative and is slow to participate in physically active tasks or
activities.
Students Section Summary scores suggest he may have challenges processing information from the auditory,
visual and movement systems. Student almost always appears to to not hear and seems oblivious within an
active environment. He frequently misses oral directions in class more than other students. He notices small
changes an is frequently slow to participate in physically active tasks/activities and withdraws from them.
Reading: Student demonstrates difficulty with comprehension following the reading of a paragraph. He has a
difficult time answering questions so it is more difficult to assess longer passages. He is clearly a phonetic reader.
This section should be in narrative form and at least 3-5 areas of concern should be listed with clear and concise
explanations.
Prior Interventions: (What interventions have been tried? How successful have these interventions been?)
All interventions tried by all teachers should be clearly discussed in this section.
General Ed and Special Ed classrooms - Classroom staff will be trained in best practices for working with children
with special needs including.
Applied behavior analysis, strategies for working on challenging behavior, sensory integration strategies and
strategies for increasing communication.
7.27% GE, 92.63% Sped
OT 30 mins/1 x monthly, PT 30 mins 2x monthly
Social/Behavior 30 mins/3x weekly; 80 mins/5x weekly

Reading 30 mins/1x weekly, 67 mins/5x weekly
Math 77 mins/5x wekly
Written language 67 mins/5x weekly
Communication 30 mins/6x monthly
Special transportation
Student characteristics: (What are the students strengths and challenges? What other student characteristics
need consideration in understanding the difficulties and concerns and planning the interventions?)
Strengths
Verbal communicator
Math count 100+, write numbers, some add/subtr facts, successfully uses TouchMath curriculum
Reading/decoding skills. Identifies and writes all 26 letters, upper and lower case. Knows letter sounds.
Accurately read 80% of 4
th
grade words, 90% of 5
th
, 60% of 6
th
. Student is a phonetic reader. He
demonstrates excellent single word comprehension and is able to match words to corresponding pictures.
Loves to draw, write and play on the iPad and will engage in those activities for long periods of time.
Very fast writer. Wrote two 4
th
and 5
th
grade sentences missing one word.
Making progress to identify coin names and values and telling time to the half hour. Student can tell time
to the hour, averaging 61%.
Be sure to list both strengths as well as any additional challenges that may impact the childs success in school.
Student Present Levels, Goals, and Objectives: (What are the student's present levels of functioning in the
current IEP in reading, math, writing, social skills, communication, fine motor, and gross motor skills? What are
the student's current goals in these areas? Have they been met? Are they continuing?)
All goals have not yet been met and are continuing.
Goal Area Present Levels Annual Goal Who Is Responsible How Data will be Collected
Communication - Attention/Listening
- Student will stop activity/speaking
and look at teacher 1 of 5 attempts 4 of 5 attempts SLP
Written in Progress
Report/Trimesters
Goal Area



Present Levels



Annual Goal



Who Is Responsible



How Data will be Collected

Fine Motor - w adapted scissiors cut
to improve bilateral coord and hand
strength 0 of 3 attempts 2 of 3 attempts Sped Teacher
Written in Progress
Report/Trimesters
Fine Motor/AT - 10 finger use of
keyboard, home row 0 of 3 attempts 2 of 3 attempts OT/PT
Written in Progress
Report/Trimesters


Gross Motor - jump forward 8 inches
with 2 feet together 0 of 4 attempts 3 of 4 attempts OT/PT
Written in Progress
Report/Trimesters


Gross Motor/playground -
consistently throw and catch a ball 5
ft away 1 of 4 attempts 3 of 4 attempts OT/PT
Written in Progress
Report/Trimesters

Math/Subtraction - complete 10
problems w/out borrowing 0 of 10 attempts 9 of 10 attempts Sped Teacher
Written in Progress
Report/Trimesters



Goal Area



Present Levels



Annual Goal



Who Is Responsible



How Data will be Collected

Reading/Comprehension - read and
answer 3 comprehension questions
about a passage 0 of 3 attempts 3 of 3 attempts Sped Teacher
Written in Progress
Report/Trimesters
Sensory Motor - improve his attention
to task per verbal prompt 15 verbal prompts 5 verbal prompts Sped Teacher
Written in Progress
Report/Trimesters


Social/Behavior - 2 Step Routine -
follow 2 step routing instruction
without addl prompting 1 of 5 attempts 4 of 5 attemtps Sped Teacher
Written in Progress
Report/Trimesters


Social/Behavior - Peer Play - follow
board game rules with peer and take
turns 0 of 5 attempts 4 of 5 attempts Sped Teacher
Written in Progress
Report/Trimesters
Social/Behavior - responds with
contact info to improve community
safety 0 of 5 attempts 5 of 5 attempts Sped Teacher
Written in Progress
Report/Trimesters


Written Language - Writing - write 5
word sentence using proper 0 of 3 attempts 3 of 3 attempts Sped Teacher
Written in Progress
Report/Trimesters
punctuation, capitalization, pictures

Home, Language, Cultural, and Other Considerations: (What experiential, language, cultural, and other factors
should we consider in understanding the difficulties and concerns when designing interventions?)
Student is highly interested in technology, iPads, iPhones and computers which should be incorporated into
intervention plans and allow for transition.
His personal interests include cars, swings and literacy (creating letters using magnetic letters).
Student Related Services: What related services is this student receiving? Could your student support plan also
include goals related to these services, (e.g. OT services in fine motor; your plan assists with letter formation
techniques).
Occupational Therapy
Physical Therapy
Speech Language Pathologist

Student Accommodations and Modifications: (What are the student's accommodations and modifications in the
current IEP, in the classroom and on state and district assessment?)
Supplementary aids and services: high staff to student ratio (staff trained in best practices for working with
children with special needs including applied behavior analysis, strategies for working on challenging behavior,
sensory integration strategies and strategies for increasing communication.
Use of adapted scissors,
Subtraction problems that do not require borrowing

Goals: (What outcomes do we want for the student? List 5. Be specific.) These goals should address the concerns
that you listed in section 1 of the support plan.
1. Increase amount of time Student attends to an activity/lesson, move from 5 minutes to 15 minutes .
2. Increase the number of non-computer jargon words Student uses to express his ideas/concerns and/or
respond to questions. 0/5 to 2/5.
3. Increase engagement with peers during play. Increase the number of rounds (turn taking) from 0/4 to 2/4.
4. Reduce safety risks by increasing Students responses to requests for his identification information, 0/3 to 2/3.
5. Increase gross motor skills during playground play. Increase sliding and climbing from 0 attempts per recess to
three attempts per recess.

Intervention Plan:
1. Instructional Interventions (List five specific interventions needed during instruction. Include who
will be responsible for implementation, where and when the interventions will take place, and any
additional resources needed.)
2. Behavioral/Social Interventions (List three specific behavioral and/or social interventions needed.
Include who will be responsible for implementation, where and when the interventions will take
place, and any additional resources needed.)

Assessing the Effectiveness of the Interventions: (How will you know if the interventions are working? How will
you collect data regarding the success of the interventions? Who is responsible for collecting data? How
frequently will you gather and analyze data? Be specific.)

Student Name: Student Student Resident Name: Stephanie Rutledge
Intervention Who is Responsible When Where Resources Needed How Data will be Collected How Often
Sliding/climbing lesson PT AM, Noon Recess Big toy Tally and record attempts 2x daily
Story/texts via iPad Sped Teacher Lit Block Classroom iPad, graphic organizer Observation 1x daily
Magnetic Ltrs/Nbrs Sped Teacher Math/Lit Classroom Magnetic letters Direct observation/# redirects As needed
Tchr Led Peer Play Grp Sped Teacher Free Choice Cl/recess Games Direct observ/video or pix 1x daily
Sequence Story Cards Sped Teacher Lit Block Classroom Sequence Cards Direct observ 1x daily
Read Aloud Sped Teacher AM Classroom Texts, whole gr organizer Movement of pieces 1x daily
Mental breaks 5-10 mins Sped Teacher All Classroom Timer lesson materials Observation 1x daily