Parent Consultation Form
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1PARENT CONSULTATION FORM
Pursuant to a resolution agreement among the Arizona Department of Education, the U.S. Department of Education’s Office for Civil
Rights and the U.S. Department of Justice’s Civil Rights Division, this form is to document the consultation between educators and
parents regarding English language support intervention services to students scoring composite Proficient on the AZELLA during the
period SY 2007-08 to SY 2012-13 but not proficient in reading or writing on the AZELLA and/or have not “met the standard” on AIMS
Reading or Writing.
Student Name________________________________ Grade___ IFEP or FEP (RFEP, FEP1, FEP2, FEP3, etc.)________
SAIS No.______________ District/Charter__________________________
School_____________________________
AZELLA (most recent scores): Please use PE, E, B, I, P
_____Composite Score
_____AZELLA Reading Score _____AZELLA Writing Score
Test Date__________________
FFB
A
AIMS (most recent scores): Please use
– Falls Far Below,
– Approaches, M – Meets or Exceeds the Standard
_____AIMS Reading Score
_____AIMS Writing Score
Test Date_____________________________
If an AIMS Reading or Writing Score is not available, the students’ core content grades in the last calendar year are
(transcript or report card may be attached):
_______________________________________________________
Option for enrolling student in “intervention services” is based on the following criteria:_________________________
_________________________________________________________________________________________________
Note: Additional teacher input may be attached to this form for consideration in determining appropriate intervention services.
Based upon the above information, the student named above is qualified to receive intervention services in English
language support. The following services are available (mark all that apply) and have the parent initial those elected:
Placement in SEI class focused on Reading/1 hour daily
Another class focused on Writing
Parent’s Initials: __________
Parent’s Initials: __________
Placement in SEI class focused on Writing/1 hour daily
Before School Supplemental Intervention Service
Parent’s Initials: __________
Parent’s Initials: __________
Placement in a service plan similar to an Individual
After School Supplemental Intervention Service
Language Learner Plan with intervention delivered in a
Parent’s Initials: __________
mainstream content class/daily for up to two hours
Parent’s Initials: __________
Another class focused on Reading
Before or After School Intervention Service Only
Parent’s Initials: __________
Parent’s Initials Required: __________
Services declined; Parent’s Initials Required: __________
Attach LEA-developed plan for providing services. Follow-up assessment to evaluate that the above-mentioned
services have been effective over time are required by this plan (include formative assessments and other
performance data). This completed form and the LEA-developed plan for providing services are to be placed in the
student’s cumulative file.
Teacher Signature:
Date
ELL Coordinator Signature:
Date
Parent Signature:
Date
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