TEACHER REQUEST FOR ASSISTANCE
Grade Level Support Team
Conifer High School
Student Name: *
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Teacher Name: *
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Grade Level of Student: *
Date of Referral: 10/24/2017 *
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Special Education Student: *
Second Language Student:
Type of Student Concern: *
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Describe Student Concern: Student missed a week of school and has not been able to catch up. Just talked to me about dropping AP Biology because she said she is totally lost. We have agreed to meet Thursday during seminar to brain storm a plan. Already lost her free period.
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Parent Contact:
List and Describe Communication with Parents (Include Dates and Times):
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Student Strengths (Check All That Apply):
Academic Concerns (Check All That Apply):
Behavior Concerns (Check All That Apply):
Attendance Concerns (Tardies, Absences, Skipping Class, Consistently Late, Numerous Absences Due to Illness, etc.):
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Personal Concerns of Student (Check All That Apply):
Where Does the Problem Occur (Check All That Apply):
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