Date Form Completed: Background

Initial Meeting Date: Confidential

Data Review Date(s): Information/Referral Form
A. General Information
Student: Birth Date:
School: Race/Ethnicity:
Grade: Teacher
Gender: Parents: Home Phone:
Reason for Referral:
B. Primary Concern:
1. Check the primary area(s) of concern
Academic Concerns Emotional/Behavioral Concern
Reading Listening Comprehension Learning Behaviors (attention/focus,
task/work completion, organization,
Written Expression Math study skills, motivation)

Oral Expression Other Social Behaviors (following rules, peer/

adult relationships, emotional wellbeing)
2. In what setting does the concern appear most/least often?
Most Often? Least Often?

C. Teacher Observations—for each area, rate the student in comparison to classmates using a scale from 0-5 (If
NA use 0; in the lowest 10% use 1, below average use 2, average use 3, above average use 4, and in highest 10%
use 5).
Physical and Communication Participation
Generally appears healthy Completes assignments
Normal energy level Concentrates and able to attend
Gross motor coordination Participates in class
Fine motor coordination Functions independently
Speech (articulation) Follows directions
Spoken language Sensitive to social cues
Written language Other (please specify):
Other (please specify):
Social Related Concerns (Check all that apply)
Age-appropriate self-help skills Aberrant behavior for age or school setting
Displays feelings appropriate to situation Substance abuse
Sensitive to social cues Inappropriate peer contact
Relates well to adults Personal hygiene
Relates well to peers Dress appropriately to climate
Other (please specify): Other (please specify):
D. Background Information
1. Attendance 2. Discipline Records 3. Health/Medical
1. Last Year days present Number of Discipline Reports: Screenings Date Results
days absent Number of Office Referrals: Hearing
This Year days present Number of Suspensions: Vision
days absent In School: Other
3. Retention: Yrs: Grs: Out of School: Medical History:
Total number of days: Health Conditions:
See confidential files Allergies:
Other:
4. 4. Previous enrollment in SpecEd programs/Section 504 or current SpecEd referral:.
5. Testing Information
a. ISTEP see Confidential folder b. Other District/Building Assessments
Grade Date E/LA Score / Cut M Score / Cut Instrument Grade Date Score

c. Classroom Level Assessment – Record any available assessment information from the classroom or additional
tutoring/instructional support (i.e. Title I) (may attach graphs/charts):
Subject Instrument(s) Date(s) Score(s)
Reading Aimsweb Aug. 2009 CBM – 63 MAZE - 10
Vocabulary Development
Fluency & Phrasing
Comprehension
Phonics
Phonemic Awareness
Written Expression
Writing Applications
Language Conventions
Genres/Models of Writing
Handwriting

Math
Number Sense
Computation
Algebra & Function
Geometry
Measurement
Data Analysis & Probability
Listening & Speaking
Listening Comprehension
Oral Communication
Speaking Application
 Subject Instrument(s) Date(s) Score(s)
Learning Behaviors
Attention/focus
Task Work Completion
Organization of Study Skills
Motivation
Social Behaviors (Specify)
Following School/
Classroom Rules
Peer Relationships
Adult Relationships
Emotional Well-Being
d. Grades
Current Year Previous Year Current Year Previous Year
Reading Social Studies
Writing Science
Math Health
Other

E. What are the student’s strengths, talents, or specific interests?

F. Previous/Current attempts to meet the student’s needs. Please list interventions/strategies in categories
below.
In General Education Classroom Additional Tutoring/Instructional Support Home/Community
Dates: Dates: Dates:
Intervention: Intervention: Intervention:
Impact: Impact: Impact:

Dates: Dates: Dates:

Intervention: Intervention: Intervention:
Impact: Impact: Impact:

Dates: Dates: Dates:

Intervention: Intervention: Intervention:
Impact: Impact: Impact:

G. Other Relevant Information: see confidential files