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Highly Capable Referral Questionnaire 
Please complete the following questionnaire if you would like to refer a student for Highly Capable screening. Students in grade 2 are universally screened. Students in grades 3-11 are screened by referral. Your input is valuable to this process. A separate form must be completed for each student you wish to refer.
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Email *
Your name *
Student Name *
What is your relationship to the student named above?
Student Grade *
Required
Check the following items that best describe the student as you see them. *
Consistently
Frequently
Occasionally
Seldom
Never
Advanced vocabulary for chronological age
Outstanding memory; possesses lots of information
Curious; asks endless questions (why?, “and then what?”)
Has many interests, hobbies, and collections
May have a “passionate interest” that has lasted for many years
Intense; gets totally absorbed in activities and thoughts
Sensitive to beauty and other people’s feelings and emotions
Advanced sense of justice and fairness
Aware of global issues many age peers are uninterested in
Sophisticated sense of humor, may be “class clown”
Strongly motivated to do things that interest them; may be unwilling to work on other activities
May be reluctant to move on from one subject to another
Operates on high levels of thinking compared to peers; is comfortable with abstract thinking
Perceives subtle cause-and-effect relationships
Prefers complex and challenging tasks to “basic work”
May be able to “track” two or more things simultaneously
Catches on quickly, then resists doing work, or works in a sloppy, careless manner
Comes up with better ways for doing things
Suggests above ideas to peers, teachers, and other adults
What special talents or skills does the student have? Provide examples of behavior that illustrate these skills/talents. *
Please list the student's areas of exceptional achievement. *
Please list any other information about this student that you feel is relevant in the consideration of your referral for Highly Capable screening.
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