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ChildStudyTeamReferralForm.pdf

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.