Team Use ONLY / Date:
Parent PST Letter
Vision/Hearing Screening – Pass Fail
SPED Referral

Lott Middle School

Problem Solving Team Referral Form

Student’s Name: / DOB: / Sex: / Race: / M LA B A
Referring Teacher: / Grade: / Age: / Repeater:
Yes No / Date Referred:

Background

Quarter 1 Grades Final: / Specific Concerns To Be Addressed:
Date
Average
Quarter 2 Grades Final: / Strategies Implemented by Classroom Teacher:
Date
Average
Quarter 3 Grades Final: / For Behavioral Referrals ONLY:
  • Attach Review 360 Documentation
  • Discipline Reports

Date
Average
Quarter 4 Grades Final: / These forms that MUST be attached with referral:
  • STAR Reports
  • Current Comprehensive Progress Report
  • Attendance Report
  • Classroom Tests (Major Grades)

Date
Average

Attendance

Date
Absences
Tardies

Date Date Date Date

STAR Reading PARENTPROGRESS REPORT:______

Date
Scale Score
Grade Equivalent
Percentile Rank

Date Date Date Date

STAR Math PARENTPROGRESS REPORT: ______

Date
Scale Score
Grade Equivalent
Percentile Rank

Lott Middle School

Problem Solving Team

Meeting Minutes / Referral Documentation

Name: / Math Lang. Arts Behavior Attendance
Referring Teacher: / Grade:
Problem Solving Team Signatures:
______
Principal – Date Assistant Principal - Date
______
PST Chair – Date Counselor - Date Psychometrist – Date
______
Referring Teacher – Date Special Ed Teacher– Date Teacher - Date
______
Teacher – Date Teacher - Date Teacher – Date
Month: ____ Meeting Date: ______ / Data:______
Intervention Strategies / Results: / Describe New Interventions:
Areas for Improvement / Concerns: / Additional Notes:
Tier II Tier III / PST Recommendation:
Dismiss Continue Intensify
PST Initials: ______
Month:______Meeting Date: ______ / Data: ______
Intervention Strategies / Results: / Describe New Interventions:
Areas for Improvement / Concerns: / Additional Notes:
Tier II Tier III / Progress / PST Recommendation:
Continue Intensify Dismiss Referral
PST Initials: ______
Month:______Meeting Date: ______ / Data: ______
Intervention Strategies / Results: / Describe New Interventions:
Areas for Improvement / Concerns: / Additional Notes:
Tier II Tier III / Progress / PST Recommendation:
Continue Intensify Dismiss Referral
PST Initials: ______
Month:______Meeting Date: ______ / Data: ______
Intervention Strategies / Results: / Describe New Interventions:
Areas for Improvement / Concerns: / Additional Notes:
Tier II Tier III / Progress / PST Recommendation:
Continue Intensify Dismiss Referral
PST Initials: ______
Month:______Meeting Date: ______ / Data: ______
Intervention Strategies / Results: / Describe New Interventions:
Areas for Improvement / Concerns: / Additional Notes:
Tier II Tier III / Progress / PST Recommendation:
Continue Intensify Dismiss Referral
PST Initials: ______
Month:______Meeting Date: ______ / Data: ______
Intervention Strategies / Results: / Describe New Interventions:
Areas for Improvement / Concerns: / Additional Notes:
Tier II Tier III / Progress / PST Recommendation:
Continue Intensify Dismiss Referral
PST Initials: ______
Month:______Meeting Date: ______ / Data: ______
Intervention Strategies / Results: / Describe New Interventions:
Areas for Improvement / Concerns: / Additional Notes:
Tier II Tier III / Progress / PST Recommendation:
Continue Intensify Dismiss Referral
PST Initials: ______
Month:______Meeting Date: ______ / Data: ______
Intervention Strategies / Results: / Describe New Interventions:
Areas for Improvement / Concerns: / Additional Notes:
Tier II Tier III / Progress / PST Recommendation:
Continue Intensify Dismiss Referral
PST Initials: ______