Watertown Mayer Public School ISD 111

WMES SAT Referral Packet

Student Name: ________________

Teacher Name: _________________

Referral Date:____________
SAT Meeting Date:___________

Reason for Referral (circle):

Language Arts

Math

Behavior

GENERAL STUDENT BACKGROUND INFORMATION

Parent/ Guardian Information:
Name:
Address:
Parent Involvement:
Level of Parent Involvement:

Phone:
High

Average

Low

Have parents been contacted about concerns? What was the result?
______________________________________________________________________________________
______________________________________________________________________________________
Were parents contacted about this meeting? What was the response?
______________________________________________________________________________________
______________________________________________________________________________________
Health Information:
Are there any medical or health concerns for this student? Please bring any data relating to areas of concern.
Medication student takes
Known health conditions
Vision concern
Hearing concern
Speech/Language concern

Special Services:
Does this student receive any special services throughout the day? Please circle all that apply.
Title I
Tier III Intervention
ELL Services
Speech
Social Services
Friendship Group

DATA COLLECTION: Please bring the following data if you have concerns in specific areas.
Language Arts:
SAT members will pull LA data from the shared Google
spreadsheet entitled ---Grade LA Data 14.15.

Math:
Unit Assessments
Math Fact Fluency Data

All data should be updated by classroom teachers by the

Wednesday prior to the scheduled SAT meeting.

Other classroom data specific to concern

LA Data to bring to meeting (if applicable):

Writing samples & other classroom data specific to
concern.
Behavior:
Logs of parent communication
Number of office referrals/suspensions and reasons

Behavior Charts
Other data specific to behavior concern

Watertown Mayer Public School ISD 111

WMES SAT Referral Packet

CONCERNS: Please check all that apply.
A. Achievement
__ Failing grades
__ Low or failing test scores
__ Refuses to do assignments
__ Assignments seem too hard
__ Trouble applying new learning
__ Discounts or hides skills or ability
__ Performance v. ability discrepancy
__ Lacks organization to complete assignments (homework)
__ Claims to be bored
__ Has trouble in all basic skills areas
__ Variable skill development (great strengths & great weaknesses)
__ Can read words but doesnt comprehend
__ Can calculate but cant problem solve
__ Poor spelling
__ Sentence and/or paragraph writing is poor
__ Other _________________________
B. Emotional/Behavioral
__ Demonstrates kicking, hitting, spitting or pinching, etc.
__ Self-mutilating behaviors
__ Verbally abusive
__ Destroys property
__ Becomes extremely angry or hysterical
__ Easily distractible unable to pay attention
__ Fearful cries easily
__ Prefers to be alone isolated from peers
__ Overly perfectionist
__ Not liked by others
__ Difficulty staying in one place or position
__ Pervasive unhappiness or sadness
__ Acts sad, then happy in very short time periods
__ Rigid behavior patterns ritualistic behavior
__ Preservation or obsessions with specific objects or patterns of
doing things
__ Other ____________________
C. Assistive Technology
__ Organization
__ Written language, reading, math
__ Positioning/mobility
__ Augmentative communication
D. Vision/Hearing & Health
__ Many somatic complaints _____________
__ Known health condition ______________
__ Takes medication
__ Headaches
__ Holds head close to paper
__ Regularly asks for repetitions of directions
__ Squints when reading board
__ Unusually loud or soft voice
__ Poor hygiene/body odor
__ Wetting or soiling (at school? Or at home?)
__ Seems to rely on peers for cues about what to do
__ Other ____________________________

E. Recent Life Changes

__ Death in family
__ Move to Watertown from another town
__ New family member
__ Parent job loss
__ Divorce
__ Change in medication or started new medication
__ Other __________________________
F. Language/Communication
(If concerns in this area, check with SLP to
determine the need for a screening)
__ Uses baby talk or language too young for age
__ Stutters
__ Problems expressing and organizing ideas
__ Unusual sound substitutions in word
__ Gives answers to questions that dont always
relate to the question
__ Gets words and parts of sentence mixed up
__ Difficulty pronouncing long words
__ Difficulty following oral directions
__ Doesnt comprehend rapid speech
__ Doesnt understand figurative speech forms such
as similes, metaphors, idioms, etc.
__ Trouble grasping simple word meanings
G. Motor/Sensory
__ Handwriting is very poor
__ Demonstrates hand tremor
__ Has trouble manipulating tools (ie., pencil,
scissors, keyboarding, etc.)
__ Seems unusually clumsy poor gross motor skill
__ Walks or runs in an unusual manner or has an
unusual gait
__ Seems to have trouble with balance (ie., falls or
has trouble maintaining posture in chair)
__ Seems resistant to touch
__ Other ____________________________
H. Student Strengths
__ Positive Attitude
__ Hard Worker
__ Trustworthy
__ Works well in groups
__ Respectful of authority
__ Motivated
__ Focused/goal oriented
__High expectations for self
__ Good sense of humor
__ Cooperates
__ Responsible
__ Transitions easily
__ Creative
__ Handles conflict well
__ Athletic
__ Takes pride in appearance
__ Musically talented
__ Artistically inclined
__ Other: _________________________

Watertown Mayer Public School ISD 111

WMES SAT Referral Packet

PREVIOUS INTERVENTIONS: Please list any interventions that have been implemented and the results of
the interventions. This will help the members of SAT determine the next step for the student.
Primary Concerns:

Interventions Tried:

Date:

Intervention Results:

SAMPLE INTERVENTIONS:
Reading Interventions
Incremental Rehearsal
ROAR
Pencil Tap
Rasinski
Paragraph Shrinking
Reciprocal Teaching
Click or Clunk
Anticipation Guide
QAR
FCRR Phonics and/or PA Activities
High School Intern Support
Small Group Support
1-1 Conferencing Support
Modified Curriculum Demand
Alternative Materials

Math Interventions
Incremental Rehearsal
Touch Points
Peer Tutors
Study Island (Learning Path)
Xtra Math
Math Minds
4 Step Problem Solving Approach
Draw to Clarify
Math Vocabulary Support
Number Talks
High School Intern Support
Small Group Support
1-1 Conferencing Support
Modified Curriculum Demand
Alternative Materials

Behavior Interventions
Buddy Classroom
Daily Behavior Chart
Contract
Acknowledge Positive Behavior
Assigned Seating
Arrange Physical Setting
5th Grade Buddies (Role Model)
Take a Break
Problem Solving Conference
Attendance Monitoring
Parent Communication
Parent Conference