Westmoreland Intermediate Unit

WESTMORELAND INTERMEDIATE UNIT 102 Equity Drive  Greensburg, PA 15601

NON-PUBLIC SCHOOL SERVICES – REQUEST FOR GIFTED EVALUATION

Date of Request:______Date Received at WIU: ______Student Name: ______Sex: ______Birth Date: ______Student Address:______Home telephone #: ______District of Residence:______School Attending: ______Grade: ______School Telephone #: ______Father’s Name: ______Mother’s Name: ______Father’s Address (if different than student): Mother’s Address (if different than student): ______Home Phone (Father):______Home Phone (Mother):______Work/Cell Phone (Father):______Work/Cell Phone (Mother):______

Student Referred by: ______Position/Telephone #: ______

Reason for Referral: Please describe the specific behaviors of the student in the academic and/or social-emotional- behavioral areas that have prompted this referral. ______

Other Referral Information:

 Have guidance services been provided for this student? ____ Yes ____ No If yes, please explain ______

 Is consultation with the psychologist desired? ____ Yes ____ No If yes, by ______(indicate teachers, counselor, parent, etc…)

 Are any other agencies involved with this student? ______

 Please list specific questions you would like answered as a result of this referral. ______

School Information

Request for Gifted Evaluation Form 1  Was the student ever retained? ____Yes _____No (if yes, give year and grade) ______

 What is the student’s attendance pattern? ______

 Was there a previous psychological evaluation? ____Yes ____No If yes, Date of Psychological evaluation ______Completed by:______Summary:______

 Has the student ever received an IEP and/or 504 Plan from a school district? _____Yes _____No If yes, Date of IEP or 504 Plan ______

 Has the student ever received special education services (including early intervention)? ____Yes _____No If yes, Dates and types of service: ______

 Please indicate all areas of strength:

Reading: ____Comprehension what he/she reads on a “cold reading” ____Using phonics ____Word attack ____Fluency ____Word recognition ____Using context clues ____Vocabulary Comprehension

Math: ____Solving story problems ____Understanding math concepts ____Solving math problems involving regrouping ____Math facts

Language: ____Using correct capitalization and punctuation ____Structuring complete paragraphs ____Verbal ____Using correct verb tenses ____Composing complete sentences ____Written ____Possesses adequate written expression skills ____Spelling ____Grammar ____Receptive

General/Behavioral: ____Remaining on task ____Paying Attention ____Motivation ____Turning in homework assignments ____Peer interactions ____Organizational skill ____Adult interaction ____Demonstrates persistence

 Please answer the following. a) Does the student complete assignments? ___Yes ___No b) Does the student follow oral directions? ___Yes ___No c) Does the student complete written directions? ___Yes ___No d) Does the student work well within a group? ___Yes ___No e) Does the student work well independently? ___Yes ___No f) Does the student complete homework? ___Yes ___No

 What strategies have been used in this child’s educational program to provide enrichment or acceleration to address the previously-mentioned strengths? (Specify length of time and results)______

 Please list any additional services the student is receiving (Title I, learning support, speech, tutoring, etc…):

Request for Gifted Evaluation Form 2  ** Please attach a copy of the student’s Grades and any Testing Results (SAT, ITBS, Terra Nova, etc…) ** Please attach any additional information that may be applicable (previous evaluations, outside evaluations, medical implications, any other assessment data available, etc…)

______School Administrator’s Signature Title Date

Request for Gifted Evaluation Form 3