Referral for Academic Support

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2023-2024 School Year

Student Name *

Student's current grade *

Student's current school *

Name of person making referral *

Contact information *

Please enter your phone or email address.

Reason(s) for Referral

Please check all areas of concern

Academic Concerns

Difficulty reading (sounding out) grade-level texts

Difficulty understanding what they read

Difficulty understanding grade-level math concepts

Difficulty writing/expressing thoughts clearly on paper

Difficulty mastering Social Studies or Science content

Difficulty test-tasking (understands material but struggles to show on assessments)

Extreme/sudden drop in grades

Failing two or more classes

Other:

Organizational Concerns

Not completing and/or turning in school work

Frequently loses work (or loses necessary materials to complete work)

Lacks personal organization system/skills (i.e. messy binders, messy bookbag, incomplete planner)

Demonstrates significant difficulty focusing on academic tasks

Demonstrates significant difficulty navigating complex/multi-step assignments/projects/tasks

Other:

Academic Self-Concept/Motivation Concerns

Demonstrates extreme lack of motivation around academic success/growth

Often refuses to do homework and/or other academic tasks

Expresses lack of self-confidence with academic tasks

Demonstrates anxiety related to school tasks

Other:

Please share more about the concern, if possible.

Does this student have an IEP or 504 support plan in school? *

IEP = Individualized Education Plan

Yes - They have an IEP.

Yes - They have a 504 plan.

I know they receive additional supports, but I'm not sure about an IEP.

I do not know.

No.

Other:

Other relevant/additional information:

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