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!"#"$$%& #($ )*"+,%& -.

/+%0,(1 -2%&/%0,(1

)0/."10 31#($4%0,(1
SLudenL name:

SLudenL lu number:


uaLe of 8lrLh:

Crade:


8eferral lnlLlaLed 8y:

uaLe:


LLL SLaff ConsulLed:

uaLe:


arenL/Cuardlan noLlfled 8y:

uaLe:


arenLal Concerns:


CumulaLlve lolder 8evlew CompleLed: ?es no

56"+7 8&& 96%0 8**&:
Speclal LducaLlon ALLendance roblems
revlous 1esLlng for Speclal Ld LLL 8lllngual Servlces lrequenL School Changes
CuLslde Agency Lval/ulag 1lLle l Academlc lmprovemenL lan
8eLenLlon
AddlLlonal lnformaLlon:



;$"<"10,1= 5(1+"$1<
8eadlng ulfflculLles 8ehavlor Challenges Pearlng
WrlLlng ulfflculLles ulfflculLy wlLh lnLerpersonal vlslon
8elaLlonshlps
MaLh ulfflculLles CrganlzaLlon/ALLenLlon hyslcal lmpalrmenL
CommunlcaLlon Medlcal CondlLlon 1raumaLlc 8raln ln[ury
AddlLlonal lnformaLlon:



310"$2"10,(1<
lnLervenLlon 1:
8ehavlor:


uaLe lnLervenLlon 8egun:


lan:


uaLe lnLervenLlon Lnded:


8esulLs:


lnLervenLlon lmplemenLed as planned and >%< effecLlve lnLervenLlon 4(.,#,". from orlglnal
plan and Lhen >%< effecLlve
lnLervenLlon lmplemenLed as planned and >%< 1(0 effecLlve lnLervenLlon 4(.,#,". from orlglnal and >%<
lnLervenLlon 2: 1(0effecLlve
8ehavlor:


uaLe lnLervenLlon 8egun:


lan:


uaLe lnLervenLlon Lnded:


8esulLs:


lnLervenLlon lmplemenLed as planned and >%< effecLlve lnLervenLlon 4(.,#,". from orlglnal
plan and Lhen >%< effecLlve
lnLervenLlon lmplemenLed as planned and >%< 1(0 effecLlve lnLervenLlon 4(.,#,". from orlglnal and >%<
1(0effecLlve



)0/."10 )0$"1=06< %1. 310"$"<0<?








310"&&"+0/%& @/1+0,(1,1=
Seldom SomeLlmes lrequenLly noL
Appllcable
uemonsLraLes capablllLles noL relaLed Lo school Lasks
8eLalns concepLs LaughL and masLers Lhem over Llme
uemonsLraLes average raLe of learnlng
knows age-approprlaLe facLual lnformaLlon
Applles learned skllls and concepLs Lo new Lasks
AddlLlonal lnformaLlon:




8+%."4,+ ;"$#($4%1+"
8eadlng Level:

WrlLlng Level:



Seldom SomeLlmes lrequenLly noL
Appllcable
ulfflculLy followlng order of maLh operaLlons or
execuLlng approprlaLe sequence of sLeps
8eads grade level slghL vocabulary
uses word aLLack skllls for readlng
undersLands maLerlal read Lo her or hlm
Comprehends lndependenLly read maLerlal as LexL
lncreases ln lengLh and complexlLy
ulfflculLy answerlng why/how quesLlons
CalculaLes numbers aL grade level
Applles maLh skllls ln problem solvlng
ulfflculLy wlLh roLe memorlzaLlon of maLh facLs
WrlLes uslng puncLuaLlon and spelllng approprlaLely
lans and organlzes LhoughLs ln wrlLlng
ulfflculLy comprehendlng cause/effecL relaLlonshlps
ConslsLenLly applles/reLalns prevlously learned skllls and
concepLs
AddlLlonal lnformaLlon:



5(44/1,+%0,(1
Seldom SomeLlmes lrequenLly noL
Appllcable
Speaks clearly (wlLhouL arLlculaLlon errors)
Speaks fluenLly (wlLhouL sLuLLerlng)
uses approprlaLe volce quallLy (ls noL hoarse or does noL
have unusual plLch)
lollows oral dlrecLlons aL a level expecLed for age/ablllLy level
Asks and responds Lo quesLlons and parLlclpaLes ln
dlscusslons on an equal basls wlLh peers
lnlLlaLes/malnLalns conversaLlon wlLh peers and adulLs ln
naLlve language
uses soclally approprlaLe language
CommunlcaLes on a varleLy of Loplcs ln order Lo relay ldeas
and geLs needs meL
uses compleLe and grammaLlcally correcL senLences

AddlLlonal lnformaLlon:



)"1<($:AB(0($
Seldom SomeLlmes lrequenLly noL
Appllcable
uemonsLraLes approprlaLe gross moLor skllls
rlnLs/wrlLes leglbly
Coples approprlaLely from board Lo paper
8esponds approprlaLely Lo vlsual, audlLory, movemenL, Louch
or sensory lnpuL ln Lhe school envlronmenL (e.g.
doesn'L overreacL Lo sensory sLlmull)
uemonsLraLes age-approprlaLe ablllLy Lo hold pencll, use
sclssors, operaLe fasLeners, open/close small
conLalners, eLc. when organlzlng and manlpulaLlng
maLerlals ln school
uemonsLraLes approprlaLe sLrengLh and endurance ln
moLor Lasks
AddlLlonal lnformaLlon:



-4(0,(1%& C D"6%2,($%&
Seldom SomeLlmes lrequenLly noL
Appllcable
WlLhdraws/lsolaLes
Anxlous/overly perfecLlonlsLlc/worrles excesslvely
ervaslvely sad/does noL express emoLlon
roblems wlLh mood (e.g. frequenL crylng, excesslvely
fearful or angry)
ulsplays physlcal sympLoms relaLed Lo worry (e.g. sleeplng
and eaLlng problems)
unusual or dlsLorLed LhoughLs or language noL based on facLs
or reallLy (e.g. Lalks abouL people ouL Lo geL hlm/her,
sees or hears Lhlngs LhaL are noL Lhere, eLc.)
hyslcally aggresses or physlcally LhreaLens oLhers
hyslcally acLlve well beyond expecLaLlon for age level
AcLs or moves wlLhouL seemlng Lo Lhlnk Lhrough
consequences or oLher's needs (e.g. grabs lLems,
Lalks ouL of Lurn)
Makes negaLlve or LhreaLenlng commenLs, or argues wlLh
CLhers
lnLeracLs approprlaLely wlLh same age peers

Pow long have Lhe behavlors raLed as frequenLly" been observed?


1he sLudenL has recelved Lhe followlng servlces aL school or ln Lhe communlLy for emoLlonal and behavlor or menLal healLh
concerns:


lndlcaLe seLLlngs LhaL emoLlonal and behavlor concerns occur (e.g. classroom, prep acLlvlLles/classes, speclallsL Llme, lunchroom,
playground, home, communlLy):


Pow many dlsmlssals or suspenslons has Lhe sLudenL recelved over Lhe lasL year?


WhaL are Lhe reason(s) for dlsmlssal or suspenslon?


AddlLlonal lnformaLlon:



@/1+0,(1%& )7,&&<
Seldom SomeLlmes lrequenLly noL
Appllcable
C8CAnlZA1lCnAL
Crganlzes maLerlals/LhoughLs
lnlLlaLes Lasks
SusLalns Lasks
CompleLes work/Lasks/requesLs aL same raLe as peers
Age approprlaLe dally llvlng and lndependenL llvlng skllls

AddlLlonal lnformaLlon:




9$%1<,0,(1 E+(4*&"0" ,# =$%." F ($ %=" GHI
Seldom SomeLlmes lrequenLly noL
Appllcable
Carrles ouL regular responslblllLles aL home, l.e.,
dlshes, cleanlng
ulscusses reallsLlc fuLure [ob posslblllLles
ulscusses reallsLlc fuLure educaLlon opporLunlLles

AddlLlonal lnformaLlon::




J"%&06 )0%0/<
School nurse:

uaLe 8evlewed:


?es no noL
Appllcable
PealLh ulagnosls or Chronlc PealLh roblem
uSM-lv MenLal PealLh ulagnosls
PealLh or medlcal condlLlon LhaL affecLs sLrengLh, endurance,
alerLness or organlzaLlon ln Lhe classroom
MedlcaLlons/1reaLmenLs
uon'L know deLalls

PealLh screenlngs ln Lhe pasL 6 monLhs:
vlslon:
ass lall uaLe ulsLance vlslon lf lalled:





Pearlng:
ass lall uaLe Lar 300Pz 1000Pz 2000Pz 4000Pz


8lghL
LefL
Pas a hlsLory of chronlc mlddle ear dysfuncLlon or falled hearlng screenlngs
8equlres ampllflcaLlon (hearlng ald, audlLory Lralnlng, eLc.)
Pas been prescrlbed correcLlve lenses

AddlLlonal lnformaLlon:



)0%1.%$.,K". 8<<"<<4"10<
uaLe AssessmenL Score

























;$,1+,*%&L< 8**$(2%&
ConLlnue wlLh regular educaLlon modlflcaLlons/lnLervenLlons
lmplemenL new regular educaLlon modlflcaLlons/lnLervenLlons
AddlLlonal lnformaLlon needed
lnLervenLlons approved. lorward Lo Chlld SLudy CommlLLee

_______________________________________ rlnclpal's SlgnaLure uaLe: _______________

56,&. )0/.: 9"%4 8+0,(1
ConducL lnlLlal evaluaLlon
uo noL conducL lnlLlal evaluaLlon (lf referral from parenL, musL send Lhe denlal of parenL requesL)

uaLe:


CommenL:



9"%4 B"4M"$<

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