Student Success Team Referral Form

(Middle and High School Version)

Please email this document to the Intervention Specialist: g.ola@aus.edu.kw

Student Name: Grade Level: DOB: Gender
-Choose one- / / -Choose one-
Parent: Advisory Teacher:

Person Making Referral: Position: Date of Referral:

/ /

Reason for Referral

Academic

Behavior

Emotional

Physical Health/ Medical

ELL Concerns
What is the student primary language?
The student has difficulty communicating his or her thoughts in English. -select-
The student has difficulty understanding and following directions in class. -select-
The student has difficulty comprehending grade level reading material. -select-
The student has difficulty using grade level vocabulary in their writing. -select-

Referral Data (please choose two)

Data Team Process (mandatory)

Classroom based assessments (work samples, quizzes, etc.)

Observations

Behavior Information (Demerits, etc.)

 Prior Interventions
Please check any interventions that you have tried and describe your intervention, how long did you use it, and its results.

Student Conference (mandatory)

Phone call/conference with Parents/Guardians (mandatory)

Behavior Intervention (daily homework contract, behavior contract, behavior chart etc.)

Classroom Accommodation (seat change, study buddy, etc.)

Instructional Accommodation (modified assignments, extra time, less questions, etc.)

Offered tutoring (whole group tutoring, one-on-one assistance, peer tutoring, etc.)

Academic Intervention (ELL strategies, Grade Improvement Plan, Mathematics Learning Plan, etc)

Conference with counselors/administration

Students anecdotal:
Student Strengths Areas of Concern
Please check all that apply: Please check all that apply:
Reading Comprehension Reading Comprehension
Math Calculation Math Calculation
Written Compression Written Compression
Oral Expression Oral Expression
Language Usage Language Usage
Shows initiative Incomplete/missing assignments
Attentive in class Uncooperative
Completes/ attempts assignments Lacks initiative
Cooperative with others Withdrawn
Follows instructions Physically aggressive
Helpful to others Lacks independent work skills
Makes/ maintains friendship Attendance/Tardiness
Negotiates compromises Appears depressed
Regular attendance Poor participation skills
Contributes to class discussion Disrespectful
Well organized Other
Has original ideas
Puts forth best effort
Other

Suggestions for Improvement Plan

FOR SST COMMITTEE ONLY

Grades
Course Grade Comments
Transcript
Credits Attempted
Credits Earned
Cumulative GPA
NWEA MAP Testing
Semester/ Year Reading Lexile
-Select-/ Language
Math

Semester/ Year Reading Lexile

-Select-/ Language Math

Support Services Currently Receiving

Counseling ELL
Tutoring Mentoring
Study skills/organization
Other

Retention -Select-
Which Grade: -Choose one-