Appendix E

Sample Collaborative Team Planning FormSummary Sheet

~T oe Referral Date: ~,Youth Name:

Meeting Dates: ~~/10/99

1 Advocate for student

2

3 (Unknown at this time)

4 Mental Health Case Manager Support for mom; coordinate services

5 I School Counselor Assist student with problem solving

6 Sp. Ed. Teacher/IEP Manager Instructor for core subjects; overall

responsible for student

7 PETeacher

8 Mainstream Support Teacher~-

5p. Ed. Department Chair

Daily instructor-~~~~~~~~

Liaison to Regular Ed Teachers

facilitate meeting/planning: access resources9

1 Service Coordinator-Mental Health (Access Mental Health resources)

2 (Peer I Support I Friend) (Support for student)

3 (High School Person)

4 (Clinician -ME~ntal Health)

(Help develop transition plan)-,: , ,

(Unknown at this time)--_c;;;",

(Instructor for one subject)5 (Mr. R -1 period a day)-

(Mr. W. SR. Ed. Teacher)6 (Earns time with his class as rein forcer)~---,.

I

I

I

.7 (Older cousin) (Support for student)

~--

(Assist with reading skills after school)8 (Tutor)

9

..I.t

80

Life Domain Profile

h-sF fs/is/evy 5 c

h-s-cy F 5 c-

sr/pe/ev

Y F S C h-cSr

h-c

h-c

Sr .

Pe

Y F S C--

Y F S C

Y F S C hLs

-sY F 5 C Ev

By F 5 c c

s

s

s

c Ev

sr/ev

ev (how h-;-:

learns) "-

ev (how he

learns) ,, 'i

sr/ev

c

Joe lets mom know she may get a call

about Mr. R's class-

Smart, knows consequences, gets to

school on time, has friendsFishing, diving, hunting, boogie boardI

diving -I Builds things easily/learns hands-on faSt ,1~ti;nCe-~~~ings

with his hands

Takes care of dogs/responsibility, chores

at home-

Follows schedule at school/good with

routines-~- ---

Takes buses/gets around community on

own-~

High interest subject works for him

Computers/ Art (games).~ -

Responds well with checked lessons &

redirection; highlighting, simplifyingRepetition; role playing; likes one-on-one

readina

c

Y F ['J c s

F c sy 5

-h-s

h-c

s

Y F-

s cfs

pe/ev

Y F

Y F

c5

~ ~~ Does well reading if with his friends who

read at his level

Responds well to rewards (if immediate)--

Mom has pulled lots of resources in

Counselor processes why he needs to do

things & he responds well ...~~ --c5

y F 5 cy F 5 c

S-Safety CSP-Cultural/Spiritual HM-Health Medical SR-Social RecreationalEV-E,clucational Nocational PE -Psychological/Emotional L-Legal

CTPF adapted from CW1, IL's CMHS Project/

Domain Key:FS -Family SupportLS-Uving SituationB-Basic Needs

81

Reading skills needed y F S c ev

y F s cGlasses -eye exam needed; has been discussed in previous

yearshm/ev

Disruptive behavior in class (to escape reading) y F s c pe/ev

pe/evy F sLack of preparation leads to acting out behavior c

Doesn't like to be embarrassed; acts out rather than

appear "stupid"Mom worried about low reading -transition to high school I

y F s c pe

y F s c ev

y F s cMom works two jobs so can't tutor at home or monitor

when suspendedfs

He is late for class (hanging out with friends) y F s c sr/ev

Use of profanity at school/home y F s c pe/sry F sMom concerned about unstructured setting in one class c ev

Joe tells school he WOI1't get consequence at home y F s c ev/pe

pe/evy F s cTeacher concerned dad may encourages defiant behavior

(attitude)yMom feels phonics ins1rruction has been ignored F s c ev

y F s cMom concerned that tapes don't teach-he just memorizes ev

School doesn't know wl,at tutor is doing y F s c ev/fs

y F s c

y F s cy F s c

y F s c

82

ACTION PLAN

Meeting Date: 2/10/99

Next Meeting 1will be (date & time): 2/20/99Youth/Student:

Parent / Guardiolns:

Facilitators:

School contact persons:

CONFIDENTIi\LITY AND ATTENDANCEI agree to honor the rights and privacy of any persons discussed in this meeting. I

agree not to di't/ulge any information regarding any family, person, or agency, which

may be referre.d to in the course of this meeting.

Mom advocate

special ed. classroom teacher IEP case management & instruction for core

subjectsmainstream support teacher lesson for reg. ed. classes

processes behavioral issues with student; he

seeks her out

school counselor

PE teacher daily instructor

special ed. department chair access resources; coordinate planning

--

support to family; coordinate servicesmental health ca~ie manager

mental health car'e coordinator ensures access to mental health services

---

IMMEDIATE SAFETY PLAN (describe specific safety needs; strengths and strategies):

83

Domain to be addressed

participate in PE responds well to routine Be prepared for PE extra set of clothesavailable(PE teacher next

day)be prepared for allclasses

responds well torepetition, routine

be prepared foracademics classes

1 st period teacher to do

check-in for all classes

daily

improve behavior in

Mr. R's classpositive behavior

support plan for Mr.R's class

structure, routine,reinforcement work well

similar process/mtg withMr. R. to gain his

perspective, share info and

develop plandecrease swearing generalize appropriate

language across

settings

responds to structureand immediatereinforcement, contractwith one teacher is

working, replacementword at home isworking, repetition &rewards work

teachers to share contract

and implement replacementword strategy withconsistent reinforcementfrom all teachers (special

ed. teacher to coordinatethat week)BeQin data collection

increase readingskills to 4th gradelevel

consistent, appropriatereading instruction,practice and practice

computers,reinforcement works,likes to tutor, phonics

lessons seem to be

working

1) order and use

computerized materials

2) coordinate instructionalstrategies with tutor3) access D.I. materials/process in special ed. classand with tutor

4) get specialized eye exam

5) exolore Readina Recovery

begin planing with high

school team (Sp. Ed.

Department chair to

coordinate & set meeting

for March)

caring team

family support

a structured plan toguide transition to highschool

smooth transition to

high school

has friends, respondswell to reinforcement &routine & contracts

collect data to

determine antecedents.

frequency. settingevents

decrease

altercations withadults outside ofclassroom

special ed. teacher tocollect data over next 2

weeks review with team

(2/20/99) and design

positive behavior support

~I~~- -, £_-- £- --_£ ...:£1- :school team to meet withclinician 2/20/99

lots of caring adultsaccess to mental healthservices

clarify role/needoutcome of clinician

-

clarify teammembers' roles

84

2/10 Ev/fs 2/20/99

2/20/99

Coordinate tutor/classroom reading N/A

1 2 3 4 5

..

80:..."..,..fit~..--..,..,..~0..,.

!2/iO

-Ev

-Develop Support Plant Mr. R.

-

2/10-Ev

b:r,2/20/9

9

---i Be prepared for PE daily (clothes)

-2/10

-Ev

--~! Be prepared for aU academic classes 2 3 4 5NI

A

1

--

2/10-

2/20/99---

2/20/99

2/20/99

2/20/99

2/20/99

N/ 1 2 34A

Ev---

Develop High School transition plan 5

--

2/10 Petey 2 3 4 5N/ 1A-

2/10 Ev

Collect data on -altercation" with adults out-

side of classes at school

Computerized Reading materials (order) N/ 1A

-2. 3 4 5

--

2/10 Ev 2 3 4 5N/~

1

-v1O I Pe-

5

1

2 3 4

--

2/10 Add peer/natural supports to teamsr/sr/ev 2/20/99

N/ 1 2 3 4A

5

-12/10Schedu[e eye examination Nt 1 2. 3 4

AHm/fs/e

v

52/20/99~

2/10 Continue to decrease swearing across set-

tinas

---

ev/fs/pe 2/20/9i 9

85