Student: ID #: DOB: Gr.: Campus: Check all that apply. Academic Concerns: Concerns: Reading Writing/Grammar Inconsistent Performance Problems Following Directions (Written / Oral) Spelling Math Poor Retention Completing Work/Homework Behavior Concerns: all that apply. self-discipline/Disorganization Social Skills Does Not Work Independently Lacks Preparation/Off Task Disruptive to Others/Self Overactive or Distractible Speech Concerns: Check all that apply. Language Articulation Stuttering Other: Educational History: all that apply. Has this student been enrolled in §504? Yes No If Disability: “Yes”, Has student received Speech Therapy? Yes No If Service Provider: “Yes”, Has this student been referred to Special Education? Yes No DNQ Qualified: Attendance and Discipline History: Current Year: Number of Discipline Referrals (Current Year): Days Absent Days Present List All Schools: Number of Suspensions: ISS OSS Retention Years: Grades: Number of Tardies (Current Year): Language Dominance: If or Complete the following. If or M2”, Do Not Complete Section. “Yes” “PD” “No”, “M1 Is this student identified Limited English Proficient? Yes PD No M1 M2 Entry Date: HLS Date: Language: What is the student’s current category? B I A PD ESL Number of Years in Bilingual/ESL Program: Has the student attended school in another country? Yes No When did student move to the U.S.? Name of Country: Which Grades? Did student attend on a regular basis? Yes No Check all that apply. Method(s) of Instruction Learning Style Tier 1 Accommodations Effectiveness in Area of Difficulty Preferential Seating Auditory Peer Tutoring Visual Role Playing Extra Time Completion of Work Tactile/Kinesthetic Discussion/Lecture One to One Instruction Modeling/Drill Oral Testing Learning Centers Repeated Instruction Other: Re-teach/Re-test Group Instruction Other: Academic and Achievement History: Copies Must be Attached Student Report Card (both sides) State Assessment STAAR/EOC/Telpas Special Programs Folder Permanent Report Card (both sides) Benchmark Scores/Mini Marks CPALLS and/or TPRI (Previous & Current Year) Signature of Person Making Referral Date
Student: ID #: DOB: Gr.: Campus: Check all that apply. Academic Concerns: Concerns: Reading Writing/Grammar Inconsistent Performance Problems Following Directions (Written / Oral) Spelling Math Poor Retention Completing Work/Homework Behavior Concerns: all that apply. self-discipline/Disorganization Social Skills Does Not Work Independently Lacks Preparation/Off Task Disruptive to Others/Self Overactive or Distractible Speech Concerns: Check all that apply. Language Articulation Stuttering Other: Educational History: all that apply. Has this student been enrolled in §504? Yes No If “Yes”, Disability: Has student received Speech Therapy? Yes No If “Yes”, Service Provider: Has this student been referred to Special Education? Yes No DNQ Qualified: Attendance and Discipline History: Current Year: Days Present Days Absent Number of Discipline Referrals (Current Year): List All Schools: Number of Suspensions: ISS OSS Retention Years: Grades: Number of Tardies (Current Year): Language Dominance: If “Yes” or “PD” Complete the following. If “No”, “M1 or M2”, Do Not Complete Section. Is this student identified Limited English Proficient? Yes PD No M1 M2 Entry Date: HLS Date: Language: What is the student’s current category? B I A PD ESL Number of Years in Bilingual/ESL Program: Has the student attended school in another country? Yes No When did student move to the U.S.? Name of Country: Which Grades? Did student attend on a regular basis? Yes No Check all that apply. Learning Style Method(s) of Instruction in Area of Difficulty Tier 1 Accommodations Effectiveness Auditory Peer Tutoring Preferential Seating Visual Role Playing Extra Time Completion of Work Tactile/Kinesthetic Discussion/Lecture One to One Instruction Modeling/Drill Oral Testing Learning Centers Repeated Instruction Other: Re-teach/Re-test Group Instruction Other: Academic and Achievement History: Copies Must be Attached Student Report Card (both sides) State Assessment STAAR/EOC/Telpas Special Programs Folder Permanent Report Card (both sides) Benchmark Scores/Mini Marks CPALLS and/or TPRI (Previous & Current Year) Signature of Person Making Referral Date