ES Learning Support Referral Form

Student Name: ________________ Grade/Class: _____________________ Date of Birth: _________________ Date of Referral: __________________ Date of entry to ISB:_____________ Referee: _________________________ Names of Specialists: _____________________________________________________________________ Have you communicated your concerns with the students parents? Currently attending: English/ French /Writers Workshop? Level and Teacher: ____________________________________________________ Years of instruction in English: __________________________________________ Has the child had a Psycho Educational or any other outside evaluation? _________ Please state evaluation. _________________________________________________ Has the child ever received Literacy/Math Support, Learning Support, or any outside therapy at ISB or previous school? ________________________________________ What support has the child received and for how long? ________________________ _____________________________________________________________________ Are there medical needs? State needs. _____________________________________ _____________________________________________________________________ Any vision / hearing / physical impairment(s) ________________________________ _____________________________________________________________________ Is the child currently on any medication? State medication and purpose. _____________________________________________________________________ 1. Briefly describe reason for referral and provide any relevant background information:

2. Please indicate the students performance in the following areas(mark an X in the appropriate box): Learning Problem Solving Motivation Follows written instruction Follows spoken instruction Completion of tasks Ability to stay on task Ability to work in groups Completion of homework Seeks help when needed General output Writing Handwriting Legibility Presentation of work Spelling Sentence structure Grammar Note taking Essay/Story writing Proofreading Reading/Comprehension Reading accuracy(decoding) Reading comprehension Reading rate (fluency) Math Conceptual understanding Word problems Computation Behavior / Social & Emotional Skills Self-esteem Relationship with peers Relationship with teacher Behavior in class Behavior outside of class Organization of self/materials Attendance
Exceeds grade level expectations Within grade level expectations Approaching grade level expectations Well below grade level expectations Exceeds grade level expectations Within grade level expectations Approaching grade level expectations Well below grade level expectations

Exceeds grade level expectations

Within grade level expectations

Approaching grade level expectations

Well below grade level expectations

Exceeds grade level expectations

Within grade level expectations

Approaching grade level expectations

Well below grade level expectations

Exceeds grade level expectations

Within grade level expectations

Approaching grade level expectations

Well below grade level expectations

3. Gather three work samples from the student, over a two week period, that illustrate the students specific strengths and weaknesses. Please annotate the students work samples to support your reason for referral.