<p> Bering Strait School District REFERRAL FORM</p><p>Name of Student:______Date of Referral (mm/dd/yyyy):______</p><p>Age:______Birthdate (mm/dd/yyyy):______Gender:______Referred by:______Grade:______Site:______Teacher:______Parent/Guardian/Surrogate:______Work Phone:______Address:______Home Phone:______(Street/Box Number) ______(City, State, Zip) STUDENT INFORMATION SHEET</p><p>Days absent:______/______Days Suspended: ______/______(This year) (Last year) (This year) (Last year)</p><p>Grades Repeated: ______</p><p>Linguistic Background: Primary Language of Student: ______Primary Language of Home: ______</p><p>Screening Information: Vision: ______Pass/Fail Hearing: ______Pass/Fail (mm/dd/yyyy) (Circle one) (mm/dd/yyyy) (circle one)</p><p>Medications: ______</p><p>STUDENT RECORDS REVIEW</p><p>Roots/ SRI Results (in lexiles) What is this child’s tutoring schedule? ______Date ______Date ______Date ______How long has he/she received tutoring? ______Date ______</p><p>Reading Mastery Level Describe the success of interventions ______Date ______Date ______Date ______Date ______Reading Instructional Level ______Date ______Date ______Date ______Terra Nova Results (%ile) Date______Date ______Reading ______Language Arts______Bering Strait School District Mathematics ______Science ______Social Studies ______</p><p>Has this child been referred to the Solutions Team? Please describe findings. ______</p><p>Attach a copy of report cards. This year _____ Last year _____</p><p>Attach a copy of current evidence of performance. (As many as are applicable) Work samples _____ Developmental profile ______</p><p>REASON FOR REFERRAL: [ ] 1. Educational – Reading / Writing / Math [ ] 5. Behavioral/Social/Emotional [ ] 2. Communication – Speech / Language [ ] 6. Attendance/Tardy [ ] 3. Motor Skills – Fine / Gross [ ] 7. Homework [ ] 4. Hearing, vision, medical concerns [ ] 8. Daily Living Skills Please be specific in behavior terms: ______</p><p>______</p><p>Have the parents been contacted for the reason for referral? Yes ______No ______</p><p>STUDENT STRENGTHS: (inner attributes, things the child likes to do, positive resources, expectations to the behavior, or times when the problem does not occur) Bering Strait School District Revised: 5/29/07</p><p>PRE-REVERRAL INTERVENTIONS BY REFERRING TEACHER</p><p>Date Started ______Date Ended______Target Behavior/Learning Need: ______Describe Intervention: ______Outcome: data of outcome; rate of success ______Date Started______Date Ended______</p><p>Date Started ______Date Ended______Target Behavior/Learning Need: ______Describe Intervention: ______Outcome: data of outcome; rate of success ______Date Started______Date Ended______</p><p>Date Started ______Date Ended______Target Behavior/Learning Need: ______Describe Intervention: ______Outcome: data of outcome; rate of success ______Date Started ______Date Ended ______</p>