Week 3 - Assignment - Child Study Team Referral Form

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.