Threshold Learning | SimplePractice

Your info

First name

Last name

Phone

Student's Current Age

Student's Current Grade Level

Referring School Name and Address

Your Relation to this Student

Reason for care

Please provide a short history of this student's educational history.

The purpose of this screener is to determine whether this student may be an appropriate fit for participation in The Lab. It is not a diagnostic tool and does not constitute acceptance into the program. Please do not include personally identifiable information in your responses. Responses should be written in a way that allows the team to understand the student’s needs without identifying the student directly. (For example, instead of sharing "John Smith is in Ms. Garcia’s classroom during second period." please share "The student currently receives support in a self-contained setting for part of the day.")

Limited to 600 characters

To your knowledge, are the student’s parent(s) or guardian(s) aware of the school’s efforts to explore or implement additional support options for this student? Please briefly explain.

How would you describe the school’s current relationship and communication with the student’s family (e.g., frequency of communication, collaboration, areas of alignment or tension)?

Limited to 600 characters

Client Preferences

Can the student tolerate a combination of module-based and teacher led instruction?

The preferences shared in this section are collected to support individualized planning and service alignment. Responses to these questions are not exclusionary criteria for participation in The Lab. Honest and accurate responses help our team understand this student’s context and needs so that we can determine how to best support this student and your school team.

Can the student transition between independent work and classroom instruction with support?

Does the student benefit from predictable routines and clear expectations?

Can the student remain engaged in a structed setting for increasing periods of time?

Does the student have literacy skills commensurate with same aged peers?

Explain how the student communicates their needs.

Limited to 600 characters

Explain how the student forms working relationships with at least one adult.

This question is intended to understand how the student engages with and responds to trusted adults in the school environment. This may include teachers, paraprofessionals, counselors, administrators, or other staff members. Responses may describe factors such as trust, communication style, responsiveness to feedback, consistency, or conditions under which the student is most successful interacting with a trusted adult.

Limited to 600 characters

Explain how the student functions in a large group / whole class instructional setting.

Explain how the student functions in a small group / breakout instructional setting.

Explain how the student functions in a one-on-one / independent instructional setting.

The Lab is designed to support and strengthen school-based teams. The program is only effective when school teams participate as interactive partners, contributing insights, feedback, and implementation support throughout the process. By submitting this referral, the school team acknowledges that they are the primary focus and active partners in this work and agree to engage collaboratively alongside intervention development for this student.

Our team acknowledges that we are the primary focus of The Lab and we agree to engage collaboratively in intervention development with this student.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.