MARGATE CITY PUBLIC SCHOOLS

CHILD STUDY TEAM

REFERRAL FORM

STUDENT’S NAME_____________________________________DOB______________AGE_________

ADDRESS_____________________________________________________________________________

HOME PHONE_________________________________________________________________________

MOTHER_____________________________________FATHER_________________________________

                   First                                  Last Name                                  First                                  Last Name

ADDRESS, IF DIFFERENT  FROM ABOVE:

______________________________________________________________________________________

    Mother

______________________________________________________________________________________

   Father

SCHOOL____________________________H.R. TEACHER_____________________GRADE_________

RETAINED__________YES__________NO__________        GRADE (S)__________________________

DATE PARENT (S) NOTIFIED OF TEACHERS INTENTION TO MAKE REFERRAL______________

ATTENDANCE

        ABSENT OFTEN – YES_______  NO_______  TARDY OFTEN – YES ________ NO________

CURRENT EDUCATIONAL STATUS

(ATTACH COPY OF CURRENT REPORT CARD AND PROGRESS REPORTS, STUDENT’S

 SCHEDULE, RESULTS OF STANDARDIZED TEST & SUSPENSION OR DISCIPLINARY

 FORMS.)

CLASS PLACEMENT (AT TIME OF REFERRAL)

REGULAR______________________________ BASIC SKILLS______________________

        B.    ACADEMIC ACHIEVEMENT   (*USE TO DENOTE BELOW GRADE LEVEL FUNCTION)

                READING_____________________                LANGUAGE ARTS___________________

                SPELLING________________                MATH  ________________________

              SOCIAL STUDIES____________                SCIENCE_______________________

              OTHER__________________________________________________________

        C.  WORK/STUDY HABITS   (DESCRIBE)

              ____________________________________________________________________________

              ____________________________________________________________________________

              ____________________________________________________________________________

              ____________________________________________________________________________

        D.  EMOTIONAL/SOCIAL BEHAVIOR   (DESCRIBE)

              ____________________________________________________________________________

              ____________________________________________________________________________

              ____________________________________________________________________________

              ____________________________________________________________________________

2.   REASON (S) FOR REFERRAL

      STATE SPECIFIC PROBLEM(S) IN ORDER OF IMPORTANCE

___________________________________________________________________________

___________________________________________________________________________

        

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

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3.  LIST SPECIFIC INTERVENTION STRATEGIES USED AND THEIR EFFECTS TO OVERCOME

THE SPECIFIC REASON(S) FOR REFERRAL AS STATED ABOVE.  ALSO, PLEASE LIST THE LENGTH OF TIME THE INTERVENTIONS HAVE BEEN USED.

     EXAMPLES OF INTERVENTION ARE:    TEACHER/PARENT CONFERENCES, CHANGE IN

     ACADEMIC PROGRAMMING,  SHORTENED ASSIGNMENTS, MODIFIED CURRICULUM,

     HOMEWORK CLASS, BEHAVIOR MODIFICATION, ORAL TESTS, SPEECH, COUNSELING,

     ETC.

     

                WRITTEN DOCUMENTATION OF THE INTERVENTION(S) AND THE

                              EFFECT(S), IF ANY, SHALL BE MADE BY THE STAFF OF THE REGULAR

                              PROGRAM    (6:14)

                ________________________________________________________________________

                ________________________________________________________________________

                ________________________________________________________________________

                ________________________________________________________________________

                ________________________________________________________________________

DO YOU KNOW OF ANY OTHER FACTORS THAT MAY BE INTERFERING WITH HIS/HER SUCCESS IN THEIR CURRENT PROGRAM?

________________________________________________________________________

________________________________________________________________________

ADDITIONAL CONCERNS/COMMENTS

________________________________________________________________________

________________________________________________________________________

SIGNATURES OF ALL PERSONS HAVING INPUT INTO THIS REFERRAL

______________________________________                _________________________________

______________________________________                      _________________________________

_____________________________________________________                _____________________

                                        TEACHER                                              DATE

_____________________________________________________                _____________________

                           PRINCIPAL                                              DATE

***PLEASE SEND TO THE DIRECTOR OF SPECIAL EDUCATION TO ENSURE TIME FRAME IS MET.

_____________________________________________________                _____________________

                DIRECTOR OF SPECIAL EDUCATION                              DATE

_____________________________________________________                _____________________

                        SUPERINTENDENT                                       DATE

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