RtI Student Referral Form - Wiggins School District

Wiggins MS / HS RtI Student Referral Form – 2012-13To assist in assessing the nature of support needed, please indicate below any concerns you may have about the student and thestudent’s assets. Please feel free to make comments where appropriate. You are not being asked to accuse, label, or diagnose.Student: ________________________________________ Teachers: ______________________________________________________________________________Classes: ________________________________________ Grade: __________________________________________________Date: __________________________________________ Gender: M or FPlease mark the main category of your concern:o Academico Behavioralo Physicalo Social / EmotionalWhat is your specific concern? Please provide supporting data (work sample, grades, attendance, and discipline referrals).________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please check any relevant items:1. ACADEMIC PERFORMANCEASSETS:Responds to classroom instructionWorks well in teamsMotivated to do well in schoolSets personal academic goalsWorks independently when neededInitiates learning activities at appropriate levelIndicates prior knowledge for many topicsCompletes work ahead of peersDesires to learn from school and lifeAccepts failure and moves onEnjoys intrinsic motivationFollows passions and convictionsSeeks new learning opportunitiesRegulates self to accomplish goalsReports spending time on homeworkReads for pleasurePlans ahead & makes good choicesSeeks additional assistanceHas a “B” average or betterIs goal orientedWorks well one-on-oneOther:CONCERNS:BoredomExcessive dependency on the teacherAnxiety over tests/examsExtreme self criticismRefusal to accept responsibilityPerfectionismPreoccupied with school success/compulsiveDifficulty in accepting mistakesDecline in academic performanceNot responding to school classroom strategiesDecline in quality of workWork not handed inChange in classroom participationInconsistent daily workAttitude of irritation and frustrationDefensivenessPower struggles over class workDistracts peers from learning tasksDeterioration of rapport with teachersIn-school absenteeism (skipping class)Withdrawal: separates from others/lonerTardiness to classDaydreaming in classSuspensions from schoolIncomplete workCheatingSleeping in classTransition difficultiesLow self-efficacyConfused by assignmentsResists new patterns/routinesAvoids taking risksExtreme shynessOther:

2. INDIVIDUAL / PEER RELATIONSHIPSASSETS:Understands rules and consequencesPeers model responsible behaviorDemonstrates empathy, sensitivity & friendship skillsInitiates access to resources as neededResists negative peer pressureOptimistic about his/her futureSeeks to resolve conflict in a positive mannerInvolved in music or artsInvolved in sports or activities in schoolPlaces high value on helping othersActs on pro-social convictions, stands up for selfTells the truth even when it is not easyAccepts and takes personal responsibilityReceives support from 3 or more adult non-parentsHas friendsOther:CONCERNS:Disrupts others in classLack of concentrationLack of motivationExtreme negativityDefiance: breaking rulesDestruction of school propertyNeeds frequent disciplineImpaired memoryLow or flat affectInattentivenessFightingDefiance of authorityVerbally abusiveObscene language, gesturesSudden outbursts of temperMakes frequent visits to nurse/counselor (Circle one)Hyperactivity, nervousnessPreoccupation with certain problemsIntensity of feelingsImpulsive actionsCompulsive talking/chatteringKeen appreciation for artistic detail in environmentIntense pursuit of certain subjectsDevelops own concepts, systems, vocabularyCan live in a world of fantasyCapacity for strong/deep attachmentsOther students concerned; possible problemTalks freely about alcohol/drug useAssociates with suspected drug usersMakes frequent trips to the bathroomOdd/inappropriate behaviorsThrows thingsMood swingsOther:

3. FAMILY ISSUES 4. COMMUNITYASSETS:Positive family communicationParental involvement in schoolFamily supports rules and consequencesFamily monitors whereabouts of studentParents support student to achieveParents are resourceful/open to servicesOther:CONCERNS:Non-participation in parent/teacher conf.Low parental involvement in schoolRunning away from schoolCaretakers other than parentsIsolating self at homeParents decline servicesOther:ASSETS:Caring neighborhoodInvolved in community serviceFeels safe in school and neighborhoodGiven useful roles in communityPerceives that adults value him/herOther:CONCERNS:Possession of alcohol &/or other drugsAny known arrests/convictionsAny involvement with juvenile officersDecreased interest in job performance or attendanceFrequent movesStudent’s culture not supported in communityVandalism (outside of school)Other:If any of the following interventions have been used, please check all that apply. Please add in others that have also been used.Intervention Type Tried? Teachers who have used this interventionTime and SupportIntensityGroupingAccelerationExplicit Systematic InstructionTargeted ReviewModelingCorrective FeedbackDirect InstructionPositive ReinforcementResponsive ScaffoldingDifferentiated InstructionSupplemental Evidence-Based CurriculumEvidence-Based Replacement CoreSummarizingMonitor with Frequent & Timely FeedbackGuided PracticeOther:

For any interventions that have been used, please describe why they HAVE or HAVE NOT been successful for the student.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Other Data to Consider: The student’s ILP All district and state assessments and data, past and present. This includes: CSAP, NWEA, DIBELS, AIMSWEB,SAT, phonemic awareness tests, and any curriculum or classroom-based assessment measures. Home-Language survey If ELL, a current CELA, and the extent, time and duration of ELL / ESL services.This includes the IELLP (Individual ELL Plan) Pertinent information from parents (notes, discussions, family information / history) Health information, including vision, hearing and a medical history. (A specific checklist of medical issues or anurse’s report / developmental-health history.)