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TEACHER REQUEST FOR ASSISTANCE
Grade Level Support Team
Conifer High School
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Student Name:
*
Your answer
Teacher Name:
*
Your answer
Grade Level of Student:
*
9th Grade
10th Grade
11th Grade
12th Grade
Date of Referral: 10/24/2017
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MM
/
DD
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YYYY
Special Education Student:
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Yes
NO
Second Language Student:
Yes
No
Clear selection
Type of Student Concern:
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Academic
Behavior
Attendance
Other:
Required
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.
Your answer
Parent Contact:
Yes
No
Clear selection
List and Describe Communication with Parents (Include Dates and Times):
Your answer
Student Strengths (Check All That Apply):
Fluent Reader
Strong Mathematical Skills
Strong Spelling Skills
Strong Language Skills
Strong Writing Skills
Skillful in Science
Skillful in Social Studies
Positive Attitude
Hard Worker
Trustworthy
Works Well in Groups
Respectful Toward Authority
Motivated
Focused/Goal Oriented
Organized
High Expectations for Self
Works Well Independently
Works Cooperatively in Teams
Responsible
Transitions Easily
Creative
Possesses Leadership Qualities
Handles Conflict Well
Athletic
Artistically Inclined
Takes Pride in Appearance
Musically Talented
Other
Other
Other:
Academic Concerns (Check All That Apply):
Word Reading
Reading Comprehension
Numerical Operations
Math Reasoning
Spelling
Written Expressions
Listening Comprehension
Oral Expression
Language
Fine Motor
Gross Motor
Articulation
Grades Declining
Disorganization
Slow Rate of Work
Incomplete Assignments
Does Not Follow Directions
Low Rate of Retention
Poor Study Skills
Gives Up Easily
Does Not Work Independently
Does Not Work Well with Others
Attention/On-Task Behavior
Other
Other
Other:
Behavior Concerns (Check All That Apply):
Verbally Disruptive
Physically Disruptive
Physically Aggressive
Sexually Aggressive
Victim of Bullying
Bullies Others
Avoided by Peers
Destroys Property
Easily Distracted
Argumentative/Defiant
Shy/Withdrawn
Hostile when Criticized
Attention Seeking Behavior
Tardy/Truant
Absent
Cheats on Tests
Easily Frustrated
Steals
Lies
Has an Uneven, usually unhappy disposition
Responds Inappropriately to Praise
Does Not Ask for Help when Needed
Lacks Motivation
Lacks Self Control
Sudden Change of Mood
Difficulty Interpreting Social Cues
Does Not Accept Responsibility
Easily Influenced by Others
Cries Frequently
Bizarre or Odd Behavior
Other
Other
Other:
Attendance Concerns (Tardies, Absences, Skipping Class, Consistently Late, Numerous Absences Due to Illness, etc.):
Your answer
Personal Concerns of Student (Check All That Apply):
Poor Hygiene
Body Odor
Overweight/Underweight
Appears Sickly
Sleeps in Class
Agitated/Nervous
Difficulty Moving/Uncoordinated
Complains of Nausea
Bloodshot Eyes
Evidence of Self-Mutilation
Burn Marks
Smells of Smoke
Smells of Alcohol
Smells of Marijuana
Other
Other
Other:
Where Does the Problem Occur (Check All That Apply):
Classroom
Hallway
Cafeteria
Gym
School Grounds
Other:
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