SSST Initial Referral Form
Please be as detailed as possible. (Updated September 2017)
Referring Teacher's Name:
Your answer
Today's Date
MM
/
DD
/
YYYY
Student's Last Name
Your answer
Student's First Name
Your answer
Student's ID Number
Your answer
Student's Date of Birth
MM
/
DD
/
YYYY
Has the student been retained?
If yes, write the grade repeated under "Other"
Does the student receive any of the following?
Check all that apply
Required
What other teachers/staff routinely work with the student?
Check all that apply.
Who does the student live with?
Has the parent/guardian been notified that the student is being referred to SSST?
Contact(s) with parent/guardian
List the date, the contact type (Phone call, meeting, note home, etc), the outcome of the contact AND the parent's comments.
Your answer
Does the student have any medical (physical or mental) diagnoses known to you?
If yes, write the name of the diagnosis under "other".
Known medications?
Your answer
What are some of the student's positive attributes/strengths?
Check all that apply.
Required
Describe your relationship with the student:
How well do you know the student? How comfortable is the student with you? Describe something (nonacademic) that is specific to the student.
Your answer
What are some of the student's interests/hobbies?
What does he or she enjoying doing/playing?
Your answer
What concerns do you have along the student's PHYSICAL Pathway?
Check all that apply.
Required
What concerns do you have along the student's SOCIAL Pathway
Check all that apply
Required
What concerns do you have along the student's LANGUAGE Pathway
Check all that apply
Required
What concerns do you have along the student's PSYCHOLOGICAL Pathway
Check all that apply
Required
What concerns do you have along the student's ETHICAL Pathway
Check all that apply
Required
What concerns do you have along the student's COGNITIVE Pathway
Check all that apply
Required
What interventions have you already tried?
Check all that apply. Be specific if responding "Other"
Required
What is your specific concern? What support you are seeking from the SSST?
Please be as detailed as possible.
Your answer
SSST meets on the 4th Tuesday of every month at 11:10 - 12:15 pm.
Are you available to meet at this time? If not, please indicate a good time under "Other".
Required
Have you made sure to maintain and bring work samples & academic/behavioral documentation to the SSST meeting?
Submit
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