Referral to the Learning Support Specialist

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Referral to the Learning Support Specialist

Hidden
Date
MM slash DD slash YYYY
Referring Teacher Name*
第一页后一页
Email*
Section Break
Student Name*
第一页后一页
Grade*
Areas of Concern
1. Please be as specific as possible. This information will be used in assisting with the evaluation process.
2. Check major areas of concern and briefly describe the child’s behavior or performance in each area checked. If you have identified more than one area of concern, circle the area you consider to be the highest priority.*
- Academic
- Social/Emotional
- Gross/Fine Motor
- Affective (activities of daily living)
- Health Related
- Behavior
- Communication
- Other (specify below)
A. Describe Specific Concerns*
B. Describe any alternative strategy used and its outcome*
C. How often does the student’s area(s) of concern prevent him/her from being successful in class (i.e. rarely, occasionally, often, every day, etc.). Provide any additional information on the lines provided below.*
D. Do you believe the student in question requires a conversation with the Learning Support Specialist, inclusion support, or pull-out support? Explain below.*
E. Describe any additional information you believe may help us provide this student with the best learning environment possible.*