STARS – New STARS (INTERNAL) Intake Form – Sourcing Tool Entry STARS INTAKE FORM – Internal Use Only Please complete the intake form below to submit your information. Thank you! Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 8Identifying InformationSelect your Program AreaSTARS NorthSTARS SouthStudent NameFirstLastDate of Birth (yyyy/mm/dd)SchoolGradeTeacherPerson(s) Completing Intake FormFirstLastRole of Person(s) Completing ChecklistHas there been a formal diagnosis provided by a pediatrician, psychologist or other clinical professional?YesNoNextCompleting the Checklist For each of the following, check whether or not the student displays the skill independently (yes or no) Social and Emotional Development Skills The student’s ability to regulate and express emotions, form relationships, and function within family and community expectations. Relationships Follows steps in simple social interaction routines (e.g., takes turns speaking, greets people)YesNoSocial Interactions Takes turns in group activitiesYesNoShares materials with peersYesNoPlays cooperatively with others during activitiesYesNoFollows Rules and Routines Follows daily routines (e.g., hangs up coat, puts backpack away, stands in line, comes in from recess)YesNoFollows simple school rules (e.g., sits in circle, waits for a turn, works without interrupting others)YesNoFollows the directions and responds to limits set by teacherYesNoSelf Regulation Resolves conflicts in socially acceptable ways (e.g., uses language or seeks adult)YesNoControls feelings of frustration, distress, and anxiety when challenged or when mistakes are madeYesNoRefrains from stereotyped behaviour for specified amount of timeYesNoNextCompleting the Checklist For each of the following, check whether or not the student displays the skill independently (yes or no) Approaches to Learning The student’s positive attitude, enthusiasm, and motivation to apply their knowledge and skills to further their understanding of the world. Initiative and Curiousity Explores class independentlyYesNoAttention Keeps eyes on teacher at appropriate timesYesNoWatches and listens to stories to completion (ten or more minutes)YesNoStays on task during adult-directed activities (ten or more minutes)YesNoOther How does the student do in different instructional settings Individual SeatworkSmall GroupLarge GroupNextLanguage Development The student’s ability to effectively communicate with others, and their development of early literacy skills. Communicates needs and wants – Student indicates spoken words or phrasesYesNoAsks for helpYesNoFollows directionsYesNoNextRisk Assessment Please use the fields below to determine the level of probability, intensity, duration, staff management in 1:1 and environment. Enter the number that corresponds with the challenging behaviour observed/ reported. Challenging Behaviour - Aggression Probability (how frequent)Monthly or lessWeeklyDailyIntensityLow- low force impact and/or low probability of impactMedium- medium force of impact, moderate to low risk of injuryHigh- high force of impact, high potential of injuryDurationLow- less than 10 secondsMedium- less than 10 minutesHigh- over 15 minutesStaff Management in 1:1Low- staff can safely manage behaviours in 1:1Medium- staff can safely manage behaviours with minimal support from caregiver or another staffHigh- staff cannot safely manage behaviour even with support from caregiver or another staffEnvironmentLow- no significant risks present in the environmentMedium- some risks present but can be removed or blocked safely during sessionHigh- risks present that cannot be removed or blockedNextRisk Assessment Please use the fields below to determine the level of probability, intensity, duration, staff management in 1:1 and environment. Enter the number that corresponds with the challenging behaviour observed/ reported. Challenging Behaviour - Self-injurious behaviour Probability (how frequent)Monthly or lessWeeklyDailyIntensityLow- low force impact and/or low probability of impactMedium- medium force of impact, moderate to low risk of injuryHigh- high force of impact, high potential of injuryDurationLow- less than 10 secondsMedium- less than 10 minutesHigh- over 15 minutesStaff Management in 1:1Low- staff can safely manage behaviours in 1:1Medium- staff can safely manage behaviours with minimal support from caregiver or another staffHigh- staff cannot safely manage behaviour even with support from caregiver or another staffEnvironmentLow- no significant risks present in the environmentMedium- some risks present but can be removed or blocked safely during sessionHigh- risks present that cannot be removed or blockedNextRisk Assessment Please use the fields below to determine the level of probability, intensity, duration, staff management in 1:1 and environment. Enter the number that corresponds with the challenging behaviour observed/ reported. Challenging Behaviour - Other challenging behaviour Please describe this type of behaviourProbability (how frequent)Monthly or lessWeeklyDailyIntensityLow- low force impact and/or low probability of impactMedium- medium force of impact, moderate to low risk of injuryHigh- high force of impact, high potential of injuryDurationLow- less than 10 secondsMedium- less than 10 minutesHigh- over 15 minutesStaff Management in 1:1Low- staff can safely manage behaviours in 1:1Medium- staff can safely manage behaviours with minimal support from caregiver or another staffHigh- staff cannot safely manage behaviour even with support from caregiver or another staffEnvironmentLow- no significant risks present in the environmentMedium- some risks present but can be removed or blocked safely during sessionHigh- risks present that cannot be removed or blockedNextThank you! 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