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GLOUCESTER COUNTY PUBLIC SCHOOLS

Referral to Child Study Committee

Date received by Child Study Chairperson
STUDENT: / First: / Mid.: / Last:
STUDENT ID: / DOB:
SCHOOL: / Choose OneAbingdon ElementaryAchilles ElementaryBethel ElementaryBotetourt ElementaryPetsworth ElementaryT C Walker ElementaryPage MiddlePeasley MiddleGloucester High / TEACHER: / GRADE: / PSK123456789101112 / SEX: / MF / AGE:
ETHNICITY: IS THE STUDENT HISPANIC OR LATINO? / Yes / No
RACE (Check all that apply): (1) American Indian or Alaska Native (A) Asian (B) Black or African American
(P) Native Hawaiian / Other Pac Islander (W) White
BIOLOGICAL, ADOPTIVE MOTHER OR GUARDIAN: check one
MAILING ADDRESS: / Street: / City: / Zip:
911 ADDRESS: / Street: / City: / Zip:
TELEPHONE: / (Home) / (Work)
BIOLOGICAL, ADOPTIVE FATHER OR GUARDIAN: check one
MAILING ADDRESS: / Street: / City: / Zip:
911 ADDRESS: / Street: / City: / Zip:
TELEPHONE: (if different from above) / (Home) / (Work)
FOSTER PARENT: (if applicable)
MAILING ADDRESS: / Street: / City: / Zip:
911 ADDRESS: / Street: / City: / Zip:
TELEPHONE: / (Home) / (Work)
IF CHILD IS IN CUSTODY OF DSS, INDICATE CASE WORKER: / CONTACT #:
REFERRING SOURCE:
TEACHERS:
[Please indicate other teachers that work with this student (i.e. other teachers on your team, Title I, other special programs)]

I. PARENT CONFERENCE/CONTACT RECORD

Date:

A. First Contact/Attempt

School Person Making Contact:

Type of Contact: School Conference Letter/Note Home Visit Phone Call Other

Purpose:
Comments on conference:

GLOUCESTER COUNTY PUBLIC SCHOOLS

Referral to Child Study Committee

STUDENT:
Date:

B. Second Contact/Attempt

School Person Making Contact:

Type of Contact: School Conference Letter/Note Home Visit Phone Call Other

Purpose:
Comments on conference:

II. REASONS FOR REFERRAL: CHECK EACH REASON FOR REFERRING THIS STUDENT.

1. problems with learning 6. hearing problems

2. low academic performance 7. physical problems

3. behavioral-emotional problems 8. parental referral

4. visual problems 9. adaptive skills

5. speech/language problems 10. developmental delays

11. other:

III. SCHOOL HISTORY

Grades Repeated:
Discipline Information: (if appropriate attach discipline referral printout)
Attendance/Tardy Concerns: (indicate year and amount)

IV. STANDARDIZED TESTING INFORMATION (NOT APPLICABLE FOR PRESCHOOL CHILDREN):

Subtest / Test: / Date: / Test: / Date: / Test: / Date:
Reading
Language
Math
Total Battery
Other

V. RELEVANT HOME INFORMATION:

Language Spoken at home:

GLOUCESTER COUNTY PUBLIC SCHOOLS

Referral to Child Study Committee

STUDENT:

VI. HEALTH HISTORY:

Describe any serious illness or accident since birth:
Describe any concerns during early development:
Ongoing medications: (specify type, amount, and time of day administered)
Results of last hearing screening: Date:
Results of last vision screening: Date:

VII. STRENGTHS

ACADEMIC/BEHAVIOR:
Writes in concise and clear style
Reads at or above grade level
Highly developed vocabulary
Mathematics at or above grade level
Achieves at or above grade level in content areas
Receives majority grades of A and B
Works well independently
Creative and curious
Follows instructions easily
Skilled in problem solving and reasoning
Frequently contributes to class
Exceptional ability to acquire knowledge
Exceptional ability to organize, store, retrieve knowledge / Attentive
Completes assigned tasks
Does assignments promptly
Motivated to learn
Cooperative
Displays leadership
Accepts suggestions and criticisms
Appears self-confident
Popular with classmates
Courteous
Other (specify):
COMMUNICATION SKILLS:
Proficient in verbal skills
Proficient in written language
Communicates effectively with an individual
Communicates effectively in groups
Expresses thoughts, knowledge well
Speech flows smoothly
Communicates basic wants and needs
Other (specify):

GLOUCESTER COUNTY PUBLIC SCHOOLS

Referral to Child Study Committee

STUDENT:

VIII. ACADEMIC/SCHOOL PERFORMANCE: Based on your observations, evaluate the student in comparison to classmates by checking problems frequently observed.

READING: / MATH:
Difficulty with basic skills / Difficulty with addition
Difficulty with comprehension / Difficulty with subtraction
Difficulty reading text presented / Difficulty with multiplication
Poor fluency in oral reading / Difficulty with division
Other (specify): / Difficulty with math concepts
Difficulty solving word problems
Other (specify):
WRITTEN LANGUAGE/FINE MOTOR:
Difficulty with spelling
Difficulty with mechanics of writing
Difficulty organizing ideas into sentences & paragraphs
Fine motor control (cutting, coloring)
Other (specify):
What would you like the student to be able to do that he/she does not do now?
How does this student learn best (describe learning style)?

IX. SOCIAL/EMOTIONAL FUNCTIONING: Based on your observations, evaluate the student in comparison to classmates by checking problems frequently observed.

Lacks motivation

Sudden changes in mood throughout the day

Lacks self-control

Needs constant approval

Inconsistency in performance

Peer interaction

Relationship(s) with teachers

Reaction to teacher/adult correction

Compliance with rules/structure

Often disrupts instruction

Difficulty in less structured environment(s) (i.e., recess, cafeteria, changing classes)

Difficulty transitioning from one activity to another

Easily frustrated

Physical aggression

Verbal aggression

Appears depressed or withdrawn

Other (specify):

GLOUCESTER COUNTY PUBLIC SCHOOLS

Referral to Child Study Committee

STUDENT:

X. WORK-STUDY SKILLS: Based on your observations, evaluate the student in comparison to classmates by checking problems frequently observed.

Ability to follow directions given orally

Ability to follow directions given in written format

Ability to work independently

Ability to handle distractions and/or interruptions

Ability to complete assignments

Independent work Group work

Retention of information

Visual memory (sequencing information)

Auditory memory (sequencing information)

Organization of materials

Completion of homework

Completion of class work

Other (specify):

XI. SPEECH-LANGUAGE/COMMUNICATION SKILLS: Based on your observations, evaluate the student in comparison to classmates by checking problems frequently observed.

Difficulty using and understanding language

Unable to communicate basic needs and wants

Difficulty with articulation skills (i.e., speech sounds omitted, substituted, distorted)

Voice problems

Nonverbal

Reluctant to communicate in groups

Difficulty with oral expression

Other (specify):

XII. INTERVENTION STRATEGIES: Indicate interventions/strategies attempted and the results.

INTERVENTION/STRATEGY / RESULTS
Student Conference
Parent Conference
Decreased amount of written work
Decreased number of vocabulary/spelling words
Allowed extra time to complete written assignments
Decreased amount of work to copy from board/book
Decreased amount of math problems
Provided options for projects on various skill levels
Required agenda for homework assignments
Behavioral contracting to encourage self-control and responsibility
Preferential seating
Peer tutoring
School based remedial programs
Modified testing techniques (specify):
Referral to counselor
Change in schedule
Consultation with specialists
Other (specify):

SE-1 (Revised 2/13)