Daisy Arabella Only

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

□ 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

NTERVENTIONS ATTEMPTED Please indicate those that were most effective

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.