Disc 1
Steven911
Date: ______________
Child Study Team Referral Record
School District
*CONFIDENTIAL*
Student: _______________ D.O.B.:_______ Requested by: ____________________
Notes from Prior School Attended
Reason for concern/referral
Reason for recommending student to the Child Study Team check all that apply:
Academic Skills Performance/Work
Production
□ Basic reading □ Attention
□ Comprehension □ Organization
□ Math facts □ Study skills
□ Math concepts □ Time management
□ Written language □ Work completion
Behavior Other
□ Aggressive □ Articulation
□ Disruptive □ Expressive language
□ Impulsive □ Receptive language
□ Noncompliant □ Fine motor
Date: ______________
□ Off task □ Gross motor
□ Playground difficulties □ Mental health
□ Relations with adults □ Medical Issues
□ Relations with peers □ Vision, hearing
□ Social skills □ Other_______________
□ Other_______________
Please specify one primary area of concern: _______________________________ Dates of parent contact: ______________ _______________ ________________
□ Has the child had any recent emotional or physical trauma? ____________________
□ List the student’s strengths:
What might motivate the student?
What are areas of possible demotivation for the student?
I
Date: ______________
NTERVENTIONS ATTEMPTED Please indicate those that were most effective
ACADEMIC APPROXIMATE DATE IMPLEMENTED
□ Calculator for math
□ Computer for word processing
□ Extra credit options
□ Extra practice on lessons
□ Extra time for tests
□ Graphic organizers provided
□ Homework help
□ High interest materials
□ Manipulatives
□ One-on-one with an adult
□ Preferential seating
□ Peer tutoring
□ Retake tests
□ Reteach material
□ Shortened assignments
□ Simplified/repeated instructions
□ Varied instructional modes (multi-sensory learning styles)
□ Other
BEHAVIORAL APPROXIMATE DATE IMPLEMENTED
□ Consistent rule enforcement
□ Counseling
□ Frequent parent contact
□ Immediate consequences
□ Incentive program
□ Positive reinforcement
□ Posted and reviewed rules
□ Progress reports to parents
□ Recorded behavioral changes
(documentation)
□ Written behavioral contract
□ Other
Please attach at least 2 pieces of documentation supporting your concern and include student work samples to back up your observations and this check list. *Adapted from the Snohomish School District Child Study Team Referral Record.