School COPE Referral Form

This intro copy can be edited in the cms.


COPE offers consultation by pediatricians and child psychiatrists. Please specify the questions or concerns that you have about your student.



Narrative Description of Child – Teacher (IRS)

Centre for Children & Families, University of Buffalo

Instructions: In the spaces below, please describe what you see as this child's primary problems in each area and describe the effects of this child's problems in that area over the past three months. Then drag the slider towards the points that describe how much the child's problems affect each area and whether he or she needs treatment or special services for the problems (see sample below)

No Problem
Extreme Problem
No Problem
Extreme Problem
No Problem
Extreme Problem
No Problem
Extreme Problem
No Problem
Extreme Problem
No Problem
Extreme Problem

The MTA SNAP-IV Rating Scaler

(c) James M. Swanson, PhD., University of California, Irvine, CA 92715