Counselor Watch Referral Sheet

Teacher Intervention Steps for Struggling Students

Student Name:

Step 1 – Student

□ Hold individual conference(s) with student Date:

□ Fill out Student Responsibility Checklist Date:

□ Provide suggestions for improvement. What suggestions were made?

□ Provide information on after-school tutoring Date:

Step 2 – Parent

□ Notify parent/guardian of student’s problem. Date:

□ Explain performance and suggest “helpful tips” (Briefly summarize parent contact)

Step 3 – Teacher

□ Review Pearson information/records Date: (Summarize any pertinent information provided)

□ Fill out General Education Teacher Intervention Checklist

Revised 10/6/10 FARMINGTON High School General Education Teacher Intervention Checklist Student ______Teacher ______Class______Current Grade in Class:______Date______

Please mark the areas of concern that pertain to this student (check all that apply): Factors that impact ACADEMIC PERFORMANCE Incomplete or late work, drop in performance Tardiness-# of days _____ Grades slipping-Failing Inconsistent attendance-# of days______Fails quizzes/tests Sleeping in class or often drowsy Low motivation, not working up to potential Cheating Does little to no make up work Problem solving difficulties Lack of participation Reading/comprehension difficulties Following directions Problem with written expression Organizational skills difficulties Problem with verbal expression Fine Motor skills difficulties Other: BEHAVIORAL CHARACTERISTICS Defiance Bullying or intimidating others Obscene language/gestures Fighting Outbursts of temper Withdrawing from others Disruptive in class Lying or stealing Promise to improve, but behavior doesn’t change Denies any problems Student reports family problems Withdrawn/loner Avoids people who have expressed concern Poor interpersonal relationship/social skills Inappropriate sexual references/language/actions Verbal/written reference to suicide Drawing symbols (gang/cult-please note what Mood changes from day to day Defensive, argumentative, hostile or Perfectionist disrespectful Other: FAMILY Parent (s) aware of your concern Parent (s) has other concerns-please list Parent (s) has similar concerns Parent (s) are supportive Parent (s) disciplines student when rules Parent (s) does not provide consistent are broken parenting method Other: After identifying areas of concern, select and implement interventions and record on back.

Revised 10/6/10 Intervention Log Sheet These are only suggested ideas for interventions; you should choose no more than 1 or 2 interventions to implement at one time. You do NOT need to try all of them! No. of weeks Which week(s) Explanation implemented: in term: (1-12) Comments: Student centered: 1 2 3 Student Conference Seating Change ______Student checklist given/discussed Increase positive comments ______Reinforcement of correct responses Extra teacher attention ______Individual instruction

Peer Centered : Peer tutoring in class Study partner in/out of class ______

Accommodations/Modifications: Modification of assignment Changing lesson plan to meet learning style Use different learning approaches ______Note taking assistance (copy of notes) Breaking task into small steps ______Extended time testing adaptation Quiet setting testing adaptation ______

Behavior/Academic Focus Clarification of behavior rules Clarification of academic rules ______Classroom contract Weekly effort report ______

Outside Assistance Sent email progress report Parent intervention (phone call) ______Parent conference Contact attendance office ______Contact with counselor

Other Intervention: ______

Teachers: Please keep accurate records of all interventions provided for this student.

You may contact Teacher Consultant, School Psychologist, or Social Workers to assist you in this data collection. If after implementation of chosen interventions, student is still failing or behavior has not changed, please provide a copy of this form to the student’s school counselor. Revised 10/6/10