School Board of St. Lucie County
Gifted Referral (for Private Schools)
DEMOGRAPHICS
Student Name
DOB
Other ID
Ethnicity
Gender
Grade
School
Primary Language
Parent/Guardian Name:
Phone (multiple)
H-
Homeroom Teacher
C-
W-
Address (Street, City, Zip)
Academic Assessment (Most recent)
Name of Assessment:
National Percentile Rank
National Percentile Rank
Reading
Math
National Percentile Rank
Science
How does this student demonstrate a need for advanced curriculum? Be specific.
Student is above social maturity of classmates?
 Yes  No
Student works above regular class curricula?  Yes  No At times 
Date of Parent Conference ____/____/____
Reason for Referral:
In order to obtain further information about your child’s abilities, we need your permission to conduct sensory, cognitive, and academic screenings with
your child. By signing below, I give permission for the educational screening of my child.
Parent and/or Guardian Signature ______________________________________________________________________ Date ____/____/____
HEARING
2000 Hz
1000 Hz
4000 Hz
R
L
Audiometric screening at 25db
Passed: __________________ Failed: _________________
RIG T
LEFT
FAR
20/___
20/___
VISION
NEAR
20/___
20/___
Circle One
P F
P F
Comments:________________________________________________
Person Responsible/Position
Muscle Balance
Plus lens (+1.75)
Color Perception
P
F
P
F
P
F
Comments:________________________________________________
Person Responsible/Position
Instrument
Used: ________________________________ Date ____/____/____
Further Evaluation Required:  Yes  No If yes, attach report.
ABILITY
VERBAL
NONVERBAL
COMPOSITE
Instrument
Used: _______________________________ Date ____/____/____
Further Evaluation Required:  Yes  No If yes, attach report.
ACADEMIC (If needed)
READING
MATH
WRITING
Standard Score - %ile
Standard Score - %ile
Standard Score - %ile
Instrument Used: _______________________ Date ____/____/____
Person Responsible: ______________________________________
Standard Score - %ile
Standard Score - %ile
Standard Score - %ile
Instrument Used: _______________________ Date ____/____/____
Person Responsible: ______________________________________
Date of Meeting: ____/____/____
Parent Letter sent on: ____/____/____
Meeting Outcome:







Further evaluation not requested at this time.
Further evaluation requested at this time. --- Obtain Consent for Formal Evaluation, and review Procedural Safeguards with parent.
Team Members Present:
School Counselor __________________________________________ Parent ____________________________________________________
School Psychologist ________________________________________ Parent ____________________________________________________
Teacher ___________________________________________________ Other _____________________________________________________
Gifted Referral for Private Schools
Rev.09/11