St. Lucie Public Schools
Gifted Referral
DEMOGRAPHICS
Student Name
DOB
Other ID
Ethnicity
Gender
Grade/School
Primary Language
Parent/Guardian Name:
Homeroom Teacher
Phone
Address (Street, City, Zip)
Benchmark Scores 3-12 (Most recent)
FCAT Level or (Most recent)
SAT-10 percentile
Reading
Reading
Student
District
Student
District
Math
Math
Student
District
Student
District
Science
Student
District
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 ____/____/____
R
L
1000 Hz
HEARING
2000 Hz
4000 Hz
Audiometric screening at 25db
Passed: __________________ Failed: _________________
RIGT
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
Instrument Used: _______________________ Date ____/____/____
Person Responsible: ______________________________________
Instrument Used: _______________________ Date ____/____/____
Person Responsible: ______________________________________
Standard Score - %ile
Standard Score - %ile
Date of Meeting: ____/____/____
Meeting Outcome:
Standard Score - %ile
Standard Score - %ile
Standard Score - %ile
Standard Score - %ile
Parent Letter sent on: ____/____/____
 Further evaluation not requested at this time.
 Further evaluation requested at this time. - Obtain Consent for Formal Evaluation (or Reevaluation for ESE students), and review Procedural
Safeguards with parent.
Team Members Present:
School Counselor __________________________________________ Parent ____________________________________________________
School Psychologist ________________________________________ Parent ____________________________________________________
Teacher ___________________________________________________ Other _____________________________________________________
Gifted Referral
STS0123 Rev.07/12