BELLEVUE SCHOOL DISTRICT SECONDARY GUIDANCE TEAM REFERRAL FORM

STUDENT NAME

GRADE

REFERRED BY

DATE OF REFERRAL STUDENT ID #

Alicia Williams

3/25/15

SCHOOL: Interlake High School

Referral Concern: is currently failing 2 classes, has been chronically tardy to Foundations of World History and has

exhibited defiant behaviors with several teachers. These patterns are very similar to behaviors that student struggled
with in middle school. student is currently receiving services from Treehouse and Cowlitz Tribal Health and we are
wondering if there is a health impairment that is significantly impacting his learning.

Current Special Services (if any)

ELL Services Case Manager:
504 Plan

Past IEP if yes, describe:

Review of Cumulative File:

Date Entered BSD: 9/6/2011
Discipline History: Short-term suspension for Failure to Comply 3-5-14, In-School Suspension for

Failure to Comply on 5-19-14, Detention for Failure to Attend on 3-24-15

Assessment Data: (or attach)
READING

WRITING

MATH

OTHER / COMMENTS

Elementary
Grades Summary

Below Standard
Approaching Standard
At Standard/Average
Above Standard

Below Standard
Approaching Standard
At Standard/Average
Above Standard

Below Standard
Approaching Standard
At Standard/Average
Above Standard

Middle School
Grades Summary

Honors LA 6th:
B-,C+, D, CHonors LA 7th:
F, C, D, F

Math 6th:
B-, D+, C, C+
Math 7th:
C+, F, D, D

A Student Learning Plan was put in

place at Highland Middle School
including interventions like Homework
Club and Tutorial.

High School
Grades Summary

See Attached

Elem. Testing

MS Testing

6th Grade MSP:

Level 3 (Proficient,
Passed)
7th Grade MSP:
Level 2 (Basic, Not
Passed)

7th Grade MSP:

Level 3
(Proficient)

6th Grade
MSP:Level 2
(Basic, Not
Passed)
7th Grade MSP:
Level 3
(Proficient)
EOC Alg:
Standard Not Met

HS Testing
Current Data:
Excused Absences:

Detentions:

3/24/15

BELLEVUE SCHOOL DISTRICT SECONDARY GUIDANCE TEAM REFERRAL FORM

STUDENT NAME

GRADE

REFERRED BY

DATE OF REFERRAL STUDENT ID #

Alicia Williams

3/25/15

Unexcused Absences: 2

Suspensions/Expulsions:

3/5/14, 5/19/14

Health Diagnoses:

Cumulative GPA:

2.86

Medication:

N/A

Speech/Language Concerns:

N/A

Current Grades
CLASS

GRADE

TEACHER & Comments

1st:PE

83%

This Student does well when we are doing something he wants or likes to

do. He still does not show the expected level of maturity. He blurts things
out at innapropriate times and talks back when the teacher asks him to do
something appropriate. He seems to be aware when his grade goes down
and will work to fix it.
2nd:FNDTN WLD 65%
HIST

Many days he's a leader, a helper, a great contributor. Many days he puts
his head down and doesn't work at all.

3rd:Floral DSGN/ 56%

MKT

This student is such a great young man!!! He is always happy and helpful!

4th:Metal Tech

75%

This student is doing just fine in Metals. He helps other students with
projects and serves as an assistant to me while I am demonstrating.
Sometimes I need to keep him on task but once I bring that to his attention
he always responds appropriately. Keep up the good work.

5th:Alg. 1

71%

6th:Hon Frosh
Comp

62%

He is missing turning in his Floral Binder, and needs to take a short quiz on
Elements of Design. He just needs to get both done.

BELLEVUE SCHOOL DISTRICT SECONDARY GUIDANCE TEAM REFERRAL FORM

STUDENT NAME

7th:Biology

50%

GRADE

REFERRED BY

DATE OF REFERRAL STUDENT ID #

Alicia Williams

3/25/15

This students behavior in Biology has improved and Ive been working
hard on developing a good relationship with him. I think we have found a
balance where I understand that he doesnt like to be pushed and he
understands that he still needs to follow the rules.
He still has days occasionally where he is resistant and opts out of doing
classwork.. but recently when this happened he came in later to make it up.
Weve had some conversations in which weve talked about the school
system and he has expressed to me that he wishes it were more like
college. He hates busy work and assignments and wants to be judged on
test scores. I offered to work a deal with him that if he would start getting
100% on tests I would forgive some missing assignments. He seemed
intrigued by this but hasnt made any changes and hasnt followed up on it.
I think he is happy to skate by doing the least amount of work required
even though he knows he is capable of more. He still declines offers of
extension activities or extra credit assignments but if I catch him at the
right moment I can ALWAYS engage him in conversation about science
topics and he loves to talk. He is curious and does a lot of research and
learning on his own time. He has deep questions and will readily engage in
conversation if he feels it is meaningful

Interventions (be prepared to share effectiveness or intervention data):

Adjusted Class Schedule

CORE Team

ELL Services

Behavior Plan

AVID

Peer Tutoring

Homework Club

Private Tutor

VIBES

504 Plan

Counseling Services

Modified Homework

Support Classes

Tutorial Schedule

Parent Conferences

Other:

Parent Contacted By:

Parent email:

Kristy Walter

Date:

4/1/2015

Phone: