School Referral Questionnaire

School Referral Questionnaire

Child’s Name:______Today’s Date:______

DOB:______Age:______Gender: Male Female

Home Address: ______

______

School:______Teacher(s):______

Presenting Problem

Briefly describe the child’s current difficulties:______

______

______

How long has this problem been of concern to you?______

When was the problem first noticed?______

What seems to make the problem worse?______

Have you noticed any changes in the child’s abilities? Yes No

If yes, please describe:______

Have you noticed any changes in the child’s behavior? Yes No

If yes, please describe:______

Has the child received an evaluation or treatment for the current problem or similar problems? Yes No

If so, please describe:______

What are the student’s current school grades?______

______

What do you want to learn from this evaluation? ______

______

Checklist

Directions: Please place a check mark next to each item that accurately describes the student. If you can’t evaluate an item, please write a question mark next to the box.

Cognitive Perceptual/Motor (con’t)

Has poor comprehension of material Has clumsy and awkward movements

Has poor short-term memory for verbal stimuli Has poor speech communication

Has poor short-term memory for nonverbal stimuli Has difficulty putting objects in correct sequence

Has limited attention span Has difficulty remembering sequence of

Has difficulty understanding oral directions objects

Has difficulty understanding written directions Has right-left confusion

Has difficulty following a sequence of directions Has poor gross-motor coordination

Misunderstands material presented at a fast pace Has poor fine-motor coordination

Has difficulty recalling story sequences Moves slowly

Has difficulty understanding teacher when he/she Has poor handwriting

moves around the room Has poor tactile discrimination

Has difficulty shifting ways of looking at or doing Behavioral

things Gives up easily

Has difficulty reasoning abstractly Has difficulty beginning tasks on time

Has difficulty conceptualizing material Has difficulty completing tasks on time

Uses problem-solving strategies inefficiently Asks questions constantly

Learns very slowly Is impulsive

Has poor long-term memory Has trouble starting and continuing tasks

Forgets newly learned skills Has difficulty changing from one assignment to another

Language/Academic Avoids doing work in class

Has difficulty decoding words Shifts often to other activities

Has poor reading comprehension Has difficulty working independently

Has poor expressive language Has difficulty playing quietly

Has poor listening comprehension Is easily distracted

Uses gestures instead of words Doesn’t seem to listen

Has difficulty rapidly naming objects Shows aggressive behavior

Has difficulty rapidly reading words Shows disruptive behavior

Has a speech impairment Talks excessively

Has difficulty producing rhymes Interrupts others often

Has difficulty recognizing similar phonemes Speaks out of turn (often blurts out)

Has difficulty arranging phonemes into words Makes comments not related to the topic

Has difficulty using verbal coding as memory aid Has difficulty remaining seated

Has difficulty using verbal coding as an aid in Fidgets often when seated

Rehearsal Does not arrive on time to class

Has poor grammar Fails to return on time to class

Has poor math computation skills Has limited persistence

Has limited math problem-solving skills Fails to do homework

Does not retain math facts Loses homework

Has poor spelling Seeks attention constantly

Has fluctuating performance Is unorganized

Has difficulty writing compositions Uses immature vocabulary

Does not know names of common objects Is slow to complete tasks

Perceptual/Motor Behaves inappropriately

Has poor auditory perception Uses drugs or alcohol

Has poor visual perception Hurts others

Behavioral (Con’t) Social (con’t)

Is cruel to animals Has difficulty making constructive

Talks about suicide contributions during group activities

Destroys others’ property Avoids others completely

Is out of chair when supposed to be doing work Has anger management problems

Has constant and repetitive behavior Displays inappropriate humor

Speaks slowly Seeks to manipulate others

Shouts or yells for no apparent reason Is rigid and opinionated

Has hallucinations Has unusual interest in sensational

Stutters violence

Injures self often Is fascinated with violence-filled

Bites nails entertainment

Bangs head Affect/Motivation

Holds breath Is easily frustrated

Does not tolerate changes in routine Shows anger quickly

Wanders aimlessly around room Has limited motivation

Is a daydreamer Is often anxious

Tires easily Is depressed or unhappy

Tells lies Has low interest in school work

Steals things Is self-critical

Has numerous physical complaints Is over excitable

Is frequently absent Is hyperactive

Has poor eye contact Has temper tantrums

Requires constant supervision Has unusual fears

Engages in dangerous behaviors Is easily annoyed

Prefers not to try new activities Frequently cries

Social Is tens and fearful

Is immature Seldom shows emotion

Is stubborn Is shy or timid

Has low self-esteem Is upset by changes in routine

Is socially isolated Has wide mood swings

Has low popularity Feels hopeless

Has difficulty communicating interests Self-Care Skills

Has difficulty accepting criticism Has poor personal hygiene

Has limited social perceptiveness Has disheveled and unclean personal

Gives in to peer pressure appearance

Is uncooperative Fails to dress appropriately for weather

Has poor skills on playground Has poor table manners in cafeteria

Is overly compliant Fails to use free time appropriately

Is selfish Engages in self-stimulating behaviors

Seems suspicious of other people Has slumped posture

Refuses to share Has rigid, tense posture

Shows sexually provocative behavior Has atypical, inappropriate posture

Blames others for problems

Has difficulty seeking help

Has difficulty accepting help from teacher

Has difficulty accepting help from peers

Does not get along with other children

Does not offer opinions and answers when

asked

Does not enjoy group activities

Does not show concern for others’ feelings

and property

solves conflicts by shouting, fighting, or

intimidating others

Strengths

Please list the child’s strengths in each of the following areas:

Cognitive:______

______

Language/academic:______

______

Perceptual/Motor:______

______

Social/Behavioral:______

______

Other comments

Please list anything else about the child that you think may be helpful.

______

______

______

______

______

______