REVIEW OF STUDENT RECORDS

For SecondaryStudent Intervention Team

This form is completed by the student’s counselor.

Counselor: / Date:
I. STUDENT INFORMATION
Student: / Birthdate:
School: / Counselor: / Grade:
Parent(s):
Address: / City: / State: / Zip:
Home Phone: / Work Phone: / Cell Phone:
Reason for Request: / Academic concerns
Behavioral issues
Parent request
Other:
II. HEALTH
Vision test results:
Hearing test results:
Diagnosis of ADD/ADHD or any other health issues:
Medications:
Outside counseling:
III. ATTENDANCE
Has the student been absent over 10 days per semester or 7 days per trimester over the last 2 years? / Days Absent
Year: / Year:
Semester 1 / Semester 1
Semester 2 / Semester 2
Semester 3 / Semester 3
Have there been any patterns observed?
IV. EDUCATIONAL HISTORY
Number of school districts attended: / Entry date to Davison:

Check where applicable

Past Sp. Ed. services/evaluations / ADD/ADHD Checklist/Conners’ / CSI
Title I / Challenge Program / Other:
Counseling / Retention
Discipline: Note number of referrals this year: / Note number of suspensions this year:
Note number of days suspended this year:

(Attach Microsage print out of last 2 years discipline)

Past Child Study Meetings (Attach all copies)
Comments:
Review of Student Records Pg. 2
V. ACADEMIC PROFILE SUMMARY
Review of Grades:(please list grades for current semester and 2 previous semesters or attach last 2 years’ transcripts):
Subject / Grade / Grade
Year / Grade
Year
Year
Language Arts / Sem. / Sem. / Sem.
Math
Science
Social Studies

Was there any year when the student’s grades, behavior, and/or attendance changed dramatically i.e. trauma with family?

Grade Accommodations:
Curriculum Adjustments:
VI. PAST EVALUATIONS

MEAP TEST RESULTS 1-2-3-4 (1-2= Meet criteria)

Grade Level / Year / Grade Level / Year

SCORE SCORE

Reading / Reading
Writing / Writing
Mathematics / Mathematics
Science / Science
Social Studies / Social Studies
WISC-III / Date:

Subtest Standard Score

Verbal Scale:
Performance Scale:
Full Scale:
Regressed Full Scale:
Verbal Comprehension:
Perceptual Organization:
WISC -IV / Date:

Subtest Standard Score

Verbal Comprehension:
Perceptual Reasoning:
Working memory:
Processing Speed:
Full Scale:
Freedom From Distractibility:

Individual Achievement Tests:

Test: / Date:
Reading grade equivalent: / National
Percentile / Math grade equivalent: / National
Percentile
Test: / Date:
Reading grade equivalent: / National
Percentile / Math grade equivalent: / National
Percentile

Microsoft Word\PF\Forms\Review of Student Records