Bill E. Young Middle School Student Study Team Referral Form

Student’s Name Grade / Referring Teacher/ Subject Date
Student Primary Language / Date of Birth / Language status: circle
EO EL RFEP IFEP
Parent / Guardian Name / Parent Phone / Other (US School Enter Date, if within 5 years)
  1. Describe this student’s strengths and positive qualities.

Able to problem solve

Articulates feelings/needs

Asks for help

Cooperates with others

Demonstrates sense of humor

Math

Reading

Follows instructions well

Makes/maintains friendships

Participates in class

Regular Attendance

Artistic/Creative

Helpful to others

Listens well /Attentive in class

Negotiates/compromises

Other: ______

  1. Describe specifically what you would like this student to be able to do in class and at school that he/she cannot, or does not, currently do. List Major Areas of Concern

______

  1. Check all that apply:

Health/Physical

Frequent Absences

Appears pale, listless

Often Sleepy

Extremely Active and Restless

Poor Motor Skills

Growth Lag

Frequent Complaints

Vision/Hearing Issues (circle)

Speech/Language

Difficulty understanding spoken language

Limited Vocabulary

Articulation problems

Short responses

Responds inappropriately

Fluency

Academic

Difficulties with _Reading __Math __Writing

Poor Retention

Poor handwriting

Difficulty staying on task

Difficulty comprehending directions

Easily Discourageed

Rate of Completion __Rushed __Slow

Difficulty changing activities

Personal/Social

Generally Withdrawn

Timid, Shy

Poor peer relations

Unhappy, moody

Exaggerates, lies

Challenges authority, defiance

Shows little empathy for others

  1. Describe any known environmental stressors or family factors that may impact this student’s functioning (e.g.; illnesses, deaths, divorce/separation, family history of learning disabilities, etc.)______
  1. Date(s) parent or guardian contacted regarding my concerns for this student ______.

Parent’s or guardian’s response or concerns:______

6. Modifications/ Interventions Checklist-

Please check modifications that you have tried to help this student and whether it was reasonably effective:

Tried? / ENVIRONMENT / Effective? / Tried? / TEACHING TECHNIQUES / Effective?
 / Change setting /  /  / Vary voice volume / 
 / Reduce distraction where possible /  /  / Use eye contact / 
 / Change class /  /  / Use hands on shoulder contact / 
 / Change group /  /  / Reduce stimulation amount/degree / 
 / Create more physical space /  /  / Teacher circulates around room / 
 / Consider physical health problems /  /  / Repeat instructions same way / 
 / Cross-age tutors /  /  / List assignments/instructions on board / 
 / Special study area /  /  / Use behavior modifications / 
 / Other______/  /  / Use visual aids in giving directions / 
 / Teach study skills / 
 / Provide individual instruction / 
 / Time out / 
Tried? / ASSIGNMENT / Effective? / Tried? / MATERIALS / Effective?
 / Simplified assignment /  /  / Use different materials, tapes / 
 / Shortened assignments /  /  / Manipulatives / 
 / Individual contracts /  /  / Task cards / 
 / Alternate Assignments /  /  / Use diagnostic materials / 
 / Use of tape recorder /  /  / Learning games / 
 / Use of notetaker /  /  / Computer / 
 / Extend time allowed for tasks /  /  / Typewriter / 
 / Buddy system /  /  / District continuums / 
 / Use of notebooks for assignments /  /  / Other______/ 
 / Other______/ 
Tried? / MISCELLANEOUS / Effective?
 / Weekly sch./home communication / 
 / Confer with other school personnel / 
 / Keep work samples / 
 / Achievement testing / 
 / Review cumulative records folder / 
 / Parent contacts / 
 / Referral to Student Wellbeeing / 
 / Referral to speech pathologist / 
 / School-based RSP services / 
 / Referral to Counseling Office / 
 / Other______/ 

Others/Notes______

School Records Review (Referring Teacher completes)

Has this student been retained?  No retentions noted Yes (List date/grade______)

Prior student study team meetings? None noted in school records Yes (List date/grade______)

Has this student had previous psychological or speech/language assessment?

None noted in cumulative records Yes (List date/grade______)

Date of last vision screening: ______Date of last hearing screening: ______

Do school records indicate a vision problem? No  Yes (is corrected with glasses) Yes (is uncorrected)

Do school records indicate a hearing problem? No Yes (is corrected with aid) Yes (is uncorrected)

Describe any known significant medical or health issues that may impact student’s academic or social functioning. Include diagnoses and current medications, if any.______

 None that I am aware of; none noted in school records

Test / SBAC Test
Date/Performance Level / Benchmark Test Results
Date /Performance Level/grade
ELA
Math

SBAC Achievement tests results (Below Standard, Approaching Standard, Meeting Standard, Exceeding Standard)

Teacher Signature: ______date ______