Elementary Student Support Team (SST) Referral
Student Name:Click here to enter text. / Date of Birth:Click here to enter text.Grade:Click here to enter text. / School:Click here to enter text.
Referral Source:Click here to enter text. / Date of Referral:Click here to enter a date.
The student’s academic, personal, and/or behavioral strengths:Click here to enter text.
Referral Reason(s): ☐ Academic ☐Behavior ☐Social/Emotional ☐Health ☐Attendance ☐ Other: ______
Problem or Concern:Click here to enter text.
How long has this been a concern?Click here to enter text.
What would you like to see as a result of the SST meeting?Click here to enter text.
How and when was the parent notified of your referral to SST? What was their response to the referral?
Click here to enter text.
Please check any areas of difficulty the student has that affect his/her school performance:
Elementary Student Support Team (SST) Referral
Attendance:
☐Tardiness
☐Absences
☐Frequent requests to leave classroom
Health:
☐Frequently sick
☐Sleeping in class/lethargic
☐Vision/Hearing
☐Other: ______
Speech/Language:
☐Articulation
☐Understanding spoken language
☐Following verbal directions
☐Expressing thoughts and ideas
☐Limited vocabulary
Reading/Written Language:
☐Letter/word identification
☐Decoding/Fluency
☐Phonemic awareness/phonics
☐Comprehension
☐Spelling
☐Mechanics
☐Organization of thoughts in writing
Mathematics:
☐Number recognition
☐Number sense
☐Computation
☐Math applications (e.g., word problems)
Behavior/Organization Skills:
☐Beginning tasks
☐Maintaining attention
☐Loses or forgets work and/or materials
☐Completing tasks
☐Overactive
☐Underactive
☐Test taking skills
☐Working Independently
☐Cooperation with others
☐Interrupts and disrupts class
Social/Emotional:
☐Self-confidence
☐Motivation
☐Low frustration tolerance
☐Inflexible
☐Sudden changes in mood throughout the day
☐Inconsistency in performance
☐Need for constant approval
☐Aggressive toward others
☐Shy/withdrawn
☐Interpreting social cues
☐Making and keeping friends
☐Accepting responsibility for behavior
***Please attach the following with your referral: Work samples, blank behavior chart (if using one), current grades, Reading Level, DIBELS scores, MSA Scores, Most recent quarterly assessment scores, Performance Series results in Reading***
Elementary Student Support Team (SST) Referral
Other concerns not already indicated:Click here to enter text.
Are there any other special considerations the SST should be aware of? (e.g., death in the family, etc.) Click here to enter text.
What have you tried to address your concerns?
Strategy / Date / Tried, No impact / Tried, some impact / By Whom?Parent/Guardian Contact / Click here / ☐ / ☐ / Click here /
Parent Conference / Click here / ☐ / ☐ / Click here /
Student Conference / Click here / ☐ / ☐ / Click here /
Extra time to complete assignments / Click here / ☐ / ☐ / Click here /
Modified assignments / Click here / ☐ / ☐ / Click here /
Preferential seating / Click here / ☐ / ☐ / Click here /
Teacher proximity / Click here / ☐ / ☐ / Click here /
Breaks / Click here / ☐ / ☐ / Click here /
Small group or 1:1 support / Click here / ☐ / ☐ / Click here /
Behavior plan/chart / Click here / ☐ / ☐ / Click here /
Peer buddy / Click here / ☐ / ☐ / Click here /
Agenda signed by staff/parent / Click here / ☐ / ☐ / Click here /
Schedule change / Click here / ☐ / ☐ / Click here /
Assistance from special educator / Click here / ☐ / ☐ / Click here /
Referral to specialist (e.g., ILT, counselor, psychologist): / Click here / ☐ / ☐ / Click here /
In school counseling (e.g., Tri-County) / Click here / ☐ / ☐ / Click here /
Researched Based Intervention group
(i.e., Fundations, Reading Recovery, Wilson, 6 minute Fluency) / Click here / ☐ / ☐ / Click here /
Other: / Click here / ☐ / ☐ / Click here /
Other: / Click here / ☐ / ☐ / Click here /
***Please attach the following with your referral: Work samples, blank behavior chart (if using one), current grades, Reading Level, DIBELS scores, MSA Scores, Most recent quarterly assessment scores, Performance Series results in Reading***