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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: / 12-15-97
Grade 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: / 540-574-3995

Parent’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 Fail
Vision 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 / Comments
running record / March 2005 / reading recovery 2 (PPA) / Fredi has difficulty with reading and has few sight words.

Math:

Assessment tool / Administration Date / Results / Comments
no formal testing, observation and work samples / 2004-2005 school year / below average

Written Language:

Assessment tool / Administration Date / Results / Comments
writing 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 / Comments
Title 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 / Comments

Current Classroom Interventions

Intervention / Duration of intervention / Comments
support 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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