Grade Level Meeting Referral Form for ILS

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Every third Wednesday of each month a grade level team of ILS teachers comes together to support students from ILS. Interventions and supports are put in place for students at risk. This form is a referral for the team to determine if students could benefit from services.

Last Name, First Name of Student *

Grade Level *

Teacher Name *

Subject Area *

Please describe the students strengths? *

Please check all areas of concern that apply: Instruction *

Fails to complete homework assignments

Turns in assignments late

Participates reluctantly in classroom activities

Fails to respond to small group instruction

Fails to respond to redirection

Disrupts class by talking out

Other:

Required

Please check all areas of concern that apply: Environment *

Frequent tardies

Frequent Absences

Frequent Bathroom/Nurse Visit

Often lacks supplies

Change in appearance or dress

Unusual weight gain or loss

Appears fatigued or overly active

Isolates self from others

Change in Peer group

Uses obscene language and gestures

Other:

Required

Does student struggle with testing? *

Yes

If yes, describe how testing is interfering with the learning process.

Which area or areas is interfering with the learning process?

Math

Reading

Writing

Critical Thinking Skills

Questioning Strategies

Please describe how one or more of these areas are interfering with the learning process?

What additional information would you like to share? *

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