Student Name: Date of Birth: Grade: School: Referral Source: Date of Referral: The student’s academic, personal, and/or behavioral strengths: Referral Reason(s): Academic Behavior Social/Emotional Health Attendance Other: _________________ Problem or Concern: How long has this been a concern? What would you like to see as a result of the SST meeting? How and when was the parent notified of your referral to SST? What was response to the referral? Class/Teacher Current Grade Behavior Comments Study Skills/ Classwork Comments CCPS Quarterly Assessments Scores (if applicable): Reading- Math- Please check any areas of difficulty the student has that affect his/her school performance: Attendance: Frequently sick Reading decoding Tardiness Sleeping in class/lethargic Reading comprehension Absences Vision/Hearing Writing mechanics Frequent requests to leave Organization of thoughts in classroom Reading/Writing/Math Skills: writing Computation Math applications (e.g., word Health: problems)
Student Name: Date of Birth: Grade: School: Referral Source: Date of Referral: The student’s academic, personal, and/or behavioral strengths: Referral Reason(s): Academic Behavior Social/Emotional Health Attendance Other: _________________ Problem or Concern: How long has this been a concern? What would you like to see as a result of the SST meeting? How and when was the parent notified of your referral to SST? What was response to the referral? Class/Teacher Current Grade Behavior Comments Study Skills/ Classwork Comments CCPS Quarterly Assessments Scores (if applicable): Reading- Math- Please check any areas of difficulty the student has that affect his/her school performance: Attendance: Tardiness Absences Frequent requests to leave classroom Health: Frequently sick Sleeping in class/lethargic Vision/Hearing Reading/Writing/Math Skills: Computation Math applications (e.g., word problems) Reading decoding Reading comprehension Writing mechanics Organization of thoughts in writing