<p> Student and Teacher Assistance and Resource Team Request for START Review *CONFIDENTIAL* Date: ______Student’s Name: ______Gender: F M Age/Grade: ______Ethnic Category: AI/A AP B H W Teacher: ______School (circle one): H K O SH VMS</p><p>REASON FOR REFERRAL: Please check the appropriate item and, if more than one, number in order of priority. ACADEMIC SOCIAL SKILLS ____ problems communicating written language ____ tends to stay to self, withdrawn ____ problems in oral communication ____ lack of peer relationships ____ weak study skills ____ lacks control in unstructured situations ____ dependent worker ____appears lonely ____ failure in one or more subject areas ____ slow in making friends ____ drop in grades, lower achievement ____disturbs other students ____ needs directions given individually ____ negative leader ____ lacks desire to do well in school ____ unyielding or stubborn on positions ____ has trouble organizing belongings ____ aggressive interaction with teacher ____ does not complete homework ____ difficulty in relating to others ____ does not ask for help when needed ____ regularly seeks to be center of attention ____ short attention span, easily distracted ____ aggressive interaction with students ____ gives up easily ____ angered by constructive criticism ____ poor short-term memory (e.g., can’t ____ teases other students remember one day to the next) ____ disrespects or defies authority ____ has demonstrated ability, but does not ____ demonstrates lack of self-confidence apply self ____ frequent ridicule from classmates ____ does not complete in-class assignments ____ appears unhappy/sad ____ other: ____ other:</p><p>DISRUPTIVE BEHAVIOR MOTOR ACTIVITY ____ fighting ____ fidgets excessively ____ defiance, violation of rules ____ has difficulty staying seated ____ blaming, denying, not accepting ____ highly active, agitated responsibility ____ cheating ____ restless, always on the go ____ sudden outbursts of anger, verbally abusive ____ far less active than peers to others ____ noisy, boisterous at inappropriate times ____ lack of impulse control ____ obscene language, gestures ____ works very slowly ____ crying for no apparent reason ____other: ____ erratic behavior ____ general changes in behavior patterns ____ other: PERTINENT BACKGROUND INFORMATION: Please check the appropriate item and elaborate, if appropriate. ____ attendance problems ____ unemployment in family ____ latchkey child ____ lives with someone other than parent ____ involvement with community agency : ____ known medical problem: ______death in the immediate family ____ currently involved with counseling ____ chronic illness in immediate family ____ previously involved with counseling ____ takes medication (specify): ____ divorce or separation ______private tutoring (describe subject area, when began and frequency): ______</p><p>**If the student is not working on grade level, please indicate their approximate grade level or grade achieved in each subject area of concern:</p><p>List the strengths of the student (at least 2-3): ______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>What specific changes are you seeking from the student? ______</p><p>______</p><p>______</p><p>______</p><p>Parent notified of Student and Teacher Assistance and Resource Team referral…</p><p>Date: ______Staff Member: ______</p><p>NOTE: A copy of the “Intervention Summary” worksheet must be completed along with any pertinent dated work samples, etc. that you feel would be helpful to the START.</p>