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Referral to Child Study Committee
Email completed form to Child Study Committee Chair at the child’s school
Student name: / Fredi Argueta-Palacios / Birthdate: / 12-15-97Grade Level: / PrekK123456789101112 / Referring source: / Sheila Shields, Kelly Bowman
Student’s teacher/team:
Other school personnel who have information related to the concern (i.e. reading specialist, ESL,guidance): Title I - Sheila Shields
Parent’s name: / Jose Argueta / Parent’s phone: / 540-574-3995Parent’s address:131 Chesnut Ridge A Harrisonburg, VA
Noncustodial parent:
Is student in foster care?
Language spoken in the home: If other, specify:
Interpreter Needed?
Date parent was notified of concern: / 3-08-05 / Form of parent contact:Phone callconferenceletterother:(If contact has not been made, referral will not be accepted)
Screening information:
Hearing Screening / Date 8-28-03 / Pass FailVision Screening / Date 11-07-03 / Pass Fail
All data entered in this document will become a part of the student’s permanent record. The information reported here will be transferred directly into the student’s record and/or IEP, should one be written.
Reason for Request:
1) The student is being referred to Child Study Committee because.
2) Present Level of Performance (assessment information gatheredwithin the last 6 weeks):
Reading:
Assessment tool / Administration Date / Results / Commentsrunning record / March 2005 / reading recovery 2 (PPA) / Fredi has difficulty with reading and has few sight words.
Math:
Assessment tool / Administration Date / Results / Commentsno formal testing, observation and work samples / 2004-2005 school year / below average
Written Language:
Assessment tool / Administration Date / Results / Commentswriting samples / March 2005 / cannot write a complete sentence by himself, has trouble with sight words
3)The student’s strengths (academic, behavioral, etc.) include : knows wrong and right, kind to others
4) The student’s weaknesses (academic, behavioral, etc.) includedifficulty making connections and following directions, does not consistently know letters/sounds, difficulty completing any tasks independently, still cannot write complete sentences by himself
History of support services (i.e., Title I, ESL, tutoring, counseling)
Service / Duration of service / CommentsTitle I / 2004-2005 school year
Special Ed. for reading and writing / February, March 2005
LEAP class for math / 2004-2005
Recommendations from IST/TAT or grade level team
Recommendation / Duration of intervention/service / CommentsCurrent Classroom Interventions
Intervention / Duration of intervention / Commentssupport from resource teacher in small group setting for reading / 2004-2005 school year
individual support in classroom / 2004-2005 school year
goes to LEAP class for math / 2004-2005 school year
List other know agencies or service providers who are currently working with or have worked with this student or family:Anita Warner - Migrant Student Advocate
CSC chair use only
Date referral was received:
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