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.
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