1. INTERVENTION & REFERRAL SERVICES

2. WHAT IS I & RS ? Intervention & Referral Services (I &RS) is a committee of professional staff members created to: * assist students who are experiencing learning, behavior or health difficulties. * provide & recommend strategies and solutions to parents & staff in order to assist in the student’s success. Intervention & Referral Services (I &RS) is a committee of professional staff members created to: * assist students who are experiencing learning, behavior or health difficulties. * provide & recommend strategies and solutions to parents & staff in order to assist in the student’s success.

3. WHO CAN BE REFERRED? Student Populations The regulations set forth that the intervention and referral services shall be provided to: "… aid students in the general education program;" (N.J.A.C. 6A:16-7.1(a)1) The regulations for intervention and referral services, however, also permit the provision of services, as appropriate, for: "… students who have been determined to be in need of special education programs and services." (N.J.A.C. 6A:16-7.1(a)2) The Intervention and referral services provided for students with disabilities shall be coordinated with the student’s IEP team, as appropriate. I & RS may not be used to delay obvious and appropriate referrals to special education (N.J.A.C. 6A:14-3 et seq..).

4. HOW ARE STUDENTS REFERRED?  Any staff member may refer students to I&RS by using a referral form obtained on the Share Drive (click District Wide Forms- I & RS and Staff Referral Forms.  Parents may request that their son or daughter be reviewed by I&RS.  Parents may request that their son or daughter be reviewed by I&RS.  Parents can initiate a referral by contacting a member of the team, the child’s guidance counselor or Assistant Principal.  Parents can initiate a referral by contacting a member of the team, the child’s guidance counselor or Assistant Principal.

5. PASCACK VALLEY HIGH SCHOOL INTERVENTION AND REFERRAL SERVICES COMMITTEE INITIAL REQUEST CONFIDENTIAL To:Intervention and Referral Services Committee From: Date: Student: Reasons for Request for Assistance (must be school-based issues, i.e. academics, behavior, school health. Be specific. Type in shaded box which will expand as you type) Please indicate the types of interventions you have tried prior to this request for assistance by checking the appropriate box. Spoke to student concerning academic performance Spoke to student concerning behavioral issues Spoke to student concerning health issues Met with student before school Met with student after school Contacted parent by phone Contacted parent by e-mail Held conference with parent in school Referred student to Guidance Referred student to the Student Assistance Counselor Referred student to the Administration__________ Other _______(Please explain by typing in the shaded box which will expand) After completing form electronically, please forward to Janice Georgallas PASCACK VALLEY HIGH SCHOOL INTERVENTION AND REFERRAL SERVICES COMMITTEE INITIAL REQUEST CONFIDENTIAL To:Intervention and Referral Services Committee From: Date: Student: Reasons for Request for Assistance (must be school-based issues, i.e. academics, behavior, school health. Be specific. Type in shaded box which will expand as you type) Please indicate the types of interventions you have tried prior to this request for assistance by checking the appropriate box. Spoke to student concerning academic performance Spoke to student concerning behavioral issues Spoke to student concerning health issues Met with student before school Met with student after school Contacted parent by phone Contacted parent by e-mail Held conference with parent in school Referred student to Guidance Referred student to the Student Assistance Counselor Referred student to the Administration__________ Other _______(Please explain by typing in the shaded box which will expand) After completing form electronically, please forward to Janice Georgallas

6. I & RS PROCESS  REQUEST ASSISTANCE  INFORMATION COLLECTION  PARENT/GUARDIAN NOTIFICATION  PROBLEM SOLVE AT MEETING  DEVELOP I & RS ACTION PLAN  SUPPORT, EVALUATE & CONTINUE WITH FOLLOW-UP PROCESS

7. DIFFERENT MODES  Collaborative Mode – In this mode, team members and the person requesting assistance jointly identify problems and, through consensus, develop and implement an I&RS action plan. The team and the requesting staff member engage in a pure form of collaboration for the resolution of educational problems.  Direct Services Mode – Immediate or specialized action, where the team takes over partial or total responsibility for implementing the I&RS action plan. An I&RS team can incorporate the functions of the drug/alcohol core team into its operations, it should be prepared to provide the direct formal or informal intervention functions of the core team. CONFIDENTIALITY MUST BE MAINTAINED  Indirect Services Mode (Consultation) – The team provides consultation services to parent or the school staff member who is requesting assistance. In the indirect services mode, the decision for action is left to the staff member or parent who is requesting assistance

8. ISSUES OF DRUGS & ALCOHOL  Direct referral to the S.A.C.  I & RS team incorporates the functions of a Core Team  Core Team – Each team member involved with drug & alcohol issues must acknowledge in writing, an understanding of FEDERAL REGULATIONS governing “Confidentiality of Alcohol and Drug Abuse Patient Records”

9. Federal Regulations governing “Confidentiality of Alcohol and Drug Abuse Patient Records” (42 CFR-2) to recipients of information including “SCHOOL BASED PROGRAMS AND STUDENT ASSISTANCE COORDINATORS” Each disclosure involving alcohol or drug information, made to the members of the Intervention & Referral Service Committee, must be kept confidential. The I & RS team falls under the umbrella of confidentiality records which are protected by Federal Law. Federal Regulations (42 CFR, Part 2) prohibits you from making any further disclosure of this information without the specific written consent of the person to whom it pertains.

10. S 2.4 Criminal penalty for violation Under 42 U.S.C. 290ee-3(f) and 42 U.S.C. 290dd-3(f), any person who violates any provision of those statutes or these regulations shall be fined not more than $500 in the case of a first offense, and not more than $ 5,000 in the case of each subsequent offense. S 2.5 Reports of violations The report of any violation of these regulations may be directed to the United States Attorney for the judicial district in which the violation occurs. I, __________________________________ am a member or Ad Hoc member of the I & RS team at Pascack Valley High School. I understand and agree that no records or information will be disclosed by me or anyone on my behalf, nor will any confidential patient identifying information be disclosed, without the written permission of the identified student. Print nameSignatureDate