5.3.24.2

Referral for Observation/Consultation

This form is used to document and communicate concerns of a parent or Teacher/Primary Caregiver to the Disabilities/Mental Health Department.

It is required to be completed and submitted if:

• A child scores in the black on either the ASQ-3 or ASQ-SE 2 (as instructed on the Information Summary sheet of both ASQ screeners).
• Rescreen status is scored as Failed or Rescreen.

It can be completed and submitted even if a child passes their screeners when Teacher/Primary Caregiver or parent/guardian have developmental, behavioral, or health concerns for which they desire consultation. If a child meets one or more criteria on the Mental Health Qualifiers form, multiple Ouch Reports and/or Supervisors Report of Accident are being written or staff are often using the Behavior Crisis Intervention Plan as a result of a child’s behavior, submit a Referral for Observation Consultation right away.

Home Visitors will assume responsibility for the entire referral process.

The Teacher/Primary Caregiver will:

1. Discuss concerns with the Family Worker and ask them to get the referral process started.
2. For concerns regarding challenging behavior in the classroom, the Challenging Behavior Tracking Packet must be completed and implemented prior to submission of the referral (see Challenging Behavior Tracking Packet).
3. For developmental/educational concerns; even if an ASQ-3 is not required for the current school year, always complete one in the area of concern(s).
4. On the Referral for Observation/Consultation (Spanish version) form, complete the Areas of Concern and list the child’s strengths and interests.
   • When completing the Areas of Concern, specify whether the concern listed is that of the teacher or parent and use objective, descriptive, fair, and unbiased observational language just as you would on a DRDP observation.
     • Subjective observation (phrases to avoid): “Joey hits because he was mad” or “Joey was out of control”
     • Objective observation: Joey resists, cries, and hits teacher
     • Parent concern: Mom reports she thinks Bob should use more words
     • Staff concern: Bob combines 2 words to express needs and desires, we have not observed the use of more than 2-word sentences in the classroom
   • Keep in mind the intention of the referral is to specify exactly what your concerns are in order to determine what action should be taken to foster the child’s development. As the child development expert, what are you seeing, or not seeing, that has raised concern?

The Family Worker/Site Supervisor will:

1. Print out the Referral for Observation/Consultation (Spanish version) form when a teacher or parent/guardian expresses concern regarding a child.
2. Complete the top portion.
   • Complete all information requested in the following sections: Child/Family, Center/Enrollment Information and Screeners (include both ASQ scores). Always include the child’s strengths and interests according to both staff and parents.
3. Give to teacher to complete the areas of concern.
4. Discuss the referral with the parent and have them sign it.
   • All referrals must be reviewed and signed by a parent or guardian. When presenting to a parent or guardian, always begin by talking about the child’s strengths and interests at school and home. When discussing a referral with a parent or guardian, please follow the guidelines described in Tips for Discussing Screening Results with Parents. If it is a developmental/educational referral, obtain parent signature on the appropriate Authorization to Release Information
5. Scan the referral to the Dis./M.H. Dept. along with the required documents.
6. Receive the Referral Response and follow any directions indicated as an Action. (Referral Response will be scanned to Family Worker by Disabilities/Mental Health Coordinator. If not received within 7 days of referral submission, contact the department). Referral Response will be signed by Family Worker and scanned back to Dis./M.H. Dept. to ensure it has been received and action steps have been completed.
7. If it is an Education Referral, the Family Worker will review the contents of the Education/Advocacy packet with the family. Be sure to document on the Disabilities Cover Sheet that the advocacy packet was provided to the family. The Advocacy Packet will be provided to the Family Worker by the Disabilities Coordinator.
8. Distribute the documentation:
   • Originals with parent’s signatures in child’s file
   • Copy of referral to parent
   • Copy of referral and release as well as any supporting documents scanned to Dis./M.H.
9. If referral is a result of a failed ASQ, complete input in Child Plus (see ASQ 3 and ASQ SE in Child Plus Manual).
10. It is primarily the responsibility of the Family Worker/Home Visitor to follow-up on the referral status.

Documents to be scanned with referrals:

• Education/Developmental Referral:
  • Current ASQ-3
  • Signed Authorization to Release Health Information
    • • Under 3 years:  FNRC 
      • SPANISH Under 3 years:  FNRC 
      • Over 3 years: Shasta County, Siskiyou County, or Trinity County
      • SPANISH Over 3 years: Shasta County, Siskiyou County, or Trinity County
• Behavior Referral:
  • Challenging Behavior Tracking Packet in its entirety
• Mental Health Referral:
  • Current ASQ SE-2
  • My Teacher Wants to Know
  • Mental Health Qualifiers if applicable
  • Challenging Behavior Tracking Packet in its entirety if staff have concerns with behavior in the classroom.

What is the difference between a Behavior and Mental Health Referral?

Mental Health Referrals are triaged directly to Shasta Head Start’s Mental Health Specialist. It will be considered a Mental Health Referral if:

• A child scores over the cutoff on the ASQ-SE 2 or if a rescreen status is still failed or rescreen regardless of whether the child has an existing diagnosis.
• At least one criterion is met on The List of Mental Health Qualifiers
  • To be completed based upon existing knowledge, not to be completed with parent/guardian.