School Board of St. Lucie County
PSET 2: Private/Home School Educational Information
Student Name
SECTION ONE: OBSERVATIONS
Student’s Strengths: Check all that apply.
Artistic
 Positive Role Model
Athletic
Positive Attitude
Flexible
Sense of Humor
Other:
Teacher Observations: Check all that apply.







Appears inattentive, easily distracted
Use of poor judgment in social and interpersonal
relationships
Constantly seeks attention-especially from adults
Reverses or confuses letters-numbers-words
Makes inappropriate responses to conversation
Frequently loses place when reading
Engages in destructive and/or aggressive behavior
Grade/School
Motivated
Confident
Perceptive







DOB ____/____/____
Inner Direction
Independent
Imaginative
Poor fine motor control
Poor gross motor control
Withdrawn
Low frustration tolerance
Difficulty completing assignments
Difficulty expressing ideas
Difficulty staying on the line
when writing







Perseverance
Trustworthy
Responsible
Friendly
Respectful
Dependable
Poor understanding of vocabulary
Difficulty following direction in sequence
Slow to react to and follow directions
Performs inconsistently from day to day
Leads or joins others in inappropriate
behavior
Impulsive-talks out-difficulty waiting turn
Misinterprets verbal questions & directions
SECTION TWO: CURRENT LEVELS
Reading Curriculum used: _______________________________________ Student’s level ____________ Current grade A B C
Math Curriculum used:__________________________________________ Student’s level ___________ Current grade A B C
Writing Curriculum used: ________________________________________ Student’s level ____________ Current grade A B C
D F
D F
D F
Interventions Tried:
 Small group instruction focusing on _______________________________________________ Beginning on ___/___/___ to ___/___/___
Delivered by _______________________________________________
 In classroom OR
 Pull out
 Individual instruction focusing on _________________________________________________ Beginning on ___/___/___ to ___/___/___
Delivered by _______________________________________________
 In classroom OR
 Pull out
SECTION THREE: REASON FOR REFERRAL
Date of Parent Conference ____/____/____
Reason for Referral:
Team Members Present:
Teacher ________ __________________________________________ Parent ____________________________________________________
Administrator ______ ________________________________________ Parent ____________________________________________________
Other _____________________________________________________ Other _____________________________________________________
SECTION FOUR: PERMISSION TO SCREEN
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 ____/____/____
School Official’s Signature __________________________________________________________________ Date ____/____/____
Created 9/2009 PSET2
STS0130