SCHOOL REFERRAL FORM

This is a comprehensive form that can be used to assess indepth information regarding academic and behavioral schematics regarding a student. Teachers, staff, counselors, school nurses, and other school personnel who wish to gather and submit information from this form will be able to provide viable input that will give additional insight into the needs of any one given student.
Name: 


  1. Child's Name:


  1. School:


  1. Grade:


  1. The child is being referred for concerns in the following areas:
    Social Skills
    Study Skills
    Academics
    Behavior


  1. Check any Exceptional Student Education Programs in which the child currently participates:
    EMH
    SED
    SLI
    GIFTED
    EH
    PI
    HI
    SLD
    OTHER:


  1. If the student currently participates in any of the Exceptional Student Education Programs please specify the degree of involvement:
    Part-time
    Full-time
    Self-contained


  1. Has this child ever been retained?
    Yes
    No


  1. If the student has been previously retained, in which grade did the retention take place?


  1. What are his/her academic strengths?


  1. Please list specific subjects and areas where this student may need additional help:


  1. From you experience with the student, how does this child compare with other students in the following area of concern: ACADEMIC PERFORMANCE
        1 2 3 4 5
    WELL BELOW AVERAGE  
    BELOW AVERAGE  
    AVERAGE  
    ABOVE AVERAGE  
    WELL ABOVE AVERAGE  


  1. From you experience with the student, how does this child compare with other students in the following area of concern: ATTITUDE TOWARD SCHOOL
        1 2 3 4 5
    WELL BELOW AVERAGE  
    BELOW AVERAGE  
    AVERAGE  
    ABOVE AVERAGE  
    WELL ABOVE AVERAGE  


  1. From you experience with the student, how does this child compare with other students in the following area of concern: SOCIAL SKILLS
        1 2 3 4 5
    WELL BELOW AVERAGE  
    BELOW AVERAGE  
    AVERAGE  
    ABOVE AVERAGE  
    WELL ABOVE AVERAGE  


  1. From you experience with the student, how does this child compare with other students in the following area of concern: SENSITITY TO OTHERS
        1 2 3 4 5
    WELL BELOW AVERAGE  
    BELOW AVERAGE  
    AVERAGE  
    ABOVE AVERAGE  
    WELL ABOVE AVERAGE  


  1. From you experience with the student, how does this child compare with other students in the following area of concern: SELF ESTEEM
        1 2 3 4 5
    WELL BELOW AVERAGE  
    BELOW AVERAGE  
    AVERAGE  
    ABOVE AVERAGE  
    WELL ABOVE AVERAGE  


  1. From you experience with the student, how does this child compare with other students in the following area of concern: POSITIVE ATTITUDE TOWARD OTHERS
        1 2 3 4 5
    WELL BELOW AVERAGE  
    BELOW AVERAGE  
    AVERAGE  
    ABOVE AVERAGE  
    WELL ABOVE AVERAGE  


  1. From you experience with the student, how does this child compare with other students in the following area of concern: VERBAL COMMUNICATION SKILLS
        1 2 3 4 5
    WELL BELOW AVERAGE  
    BELOW AVERAGE  
    AVERAGE  
    ABOVE AVERAGE  
    WELL ABOVE AVERAGE  


  1. From you experience with the student, how does this child compare with other students in the following area of concern: ABILITY TO TRUST OTHERS
        1 2 3 4 5
    WELL BELOW AVERAGE  
    BELOW AVERAGE  
    AVERAGE  
    ABOVE AVERAGE  
    WELL ABOVE AVERAGE  


  1. From you experience with the student, how does this child compare with other students in the following area of concern: STUDENT WORKS UP TO ACADEMIC POTENTIAL
        1 2 3 4 5
    WELL BELOW AVERAGE  
    BELOW AVERAGE  
    AVERAGE  
    ABOVE AVERAGE  
    WELL ABOVE AVERAGE  


  1. What is the student's current percentage grade in Math?


  1. What is the student's current percentage grade in Science?


  1. What is the student's current percentage grade in English/Language Arts/Reading?


  1. Describe this student's interaction with teachers:


  1. Describe the student's interaction with peers:


  1. After carefully reviewing this student's attendance records, do you find that the student has problems with attendance or tardiness? (Please be specific.)


  1. In what specific ways do you believe our site-based mentoring program can help this student?


  1. List any other observations and recommendations regarding the type of mentor that would best be matched with this student:


  1. Final Comments:





Mr. Hooker
Grafenwoehr Elementary School-Teacher
Vilseck High School