Brewer School Department Referral for Student Success Team
Email address *
Student Name
Your answer
Date
MM
/
DD
/
YYYY
Teacher
Your answer
Grade
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Initial Steps to be Taken
Parents Contacted
Information gathered from Parent:
Your answer
Conference with Student
Information gathered from conference with Student:
Your answer
Reviewed student file
Information gathered from student file (note past interventions):
Your answer
Requested Mandatory Witching Time Visits (Academic Support)
Information gathered from PLT Visits:
Your answer
Consulted other staff
Information gathered from other staff:
Your answer
Other Information gathered:
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Areas of Concern
Behavioral / Emotional
Area's of Concern
Work Habit
Area's of Concern
Language
Area's of Concern
Reading
Area's of Concern
Writing
Area's of Concern
Math
A clear statement of your concern:
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Student Strengths:
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Clearly describe the interventions that you are providing. You may refer to the Intervention Strategies List and record chosen interventions below:
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