St. Lucie Public Schools
PSET 1: Private/Home School Initiation
Student Name
Ethnicity
Other ID
Gender
School
DOB
Grade
Homeroom Teacher
Parent/Guardian Name:
Parent Phone:
Address (Street, City, Zip)
Please refer to the student’s cumulative record to obtain the following information.
Attendance Concerns Total Days Absent this year: ______
Health concerns
 Check if student wears glasses
 Check if student wears hearing aids
 Check if student is on medications. List here _______________________________________________
Discipline History
Prior School Year __________ Number of referrals ____
Current School Year __________ Number of referrals ____
Retention History
If yes, indicate grade level(s) retained K 1 2 3 3 4 5 6 7 8 9 10 11 12
Language History
Is the student’s 1st language English?  Yes  No If no, please identify language _________________________
Language spoken at Home: _______________________________
Parent/Guardian Consultation:
Date of Parent Conference
Reason for Referral
Student’s Strengths: Check all that apply.
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Confident; Sets high standards for self
Creative in thoughts, new ideas, seeing associations, etc.
Empathetic; Sensitive to the feelings of others
Humorous; Highly developed sense of humor
Persistent; Stays with a project until completed
Resourceful; Reasons things out in ingenious ways
Self-Starter; Engages in self-directed activities
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Appears inattentive, easily distracted
Misinterprets verbal questions & directions
Difficulty following direction in sequence
Difficulty staying on the line when writing
Impulsive-talks out-difficulty waiting turn
Performs inconsistently from day to day
Frequently loses place when reading
Teacher Observations: Check all that apply.
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Flexible ; Adapts easily to new situations
Imaginative; Verbally expressive
Inquisitive; exhibits intellectual curiosity
Leader; Well-liked by classmates
Motivated; Requires little direction
Responsible; Follows through with tasks
Venturesome; Willing to take risks
 Constantly seeks attention-especially from adults
 Reverses or confuses letters-numbers- words
 Leads or joins others in inappropriate behavior
 Use of poor judgment in social and interpersonal relationships
 Makes inappropriate responses to conversation
 Engages in destructive and/or aggressive behavior
 Slow to react to and follow directions
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Artistic / Musical
Athletic
Independent; takes initiative
Positive Attitude
Positive Role Model
Respectful
 Withdrawn
 Low frustration tolerance
 Poor fine motor control
 Poor gross motor control
 Difficulty expressing ideas
 Difficulty completing assignments
 Poor understanding of vocabulary
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
Narrative Observation:
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Completed by: ______________________________________________________________ Date: __________________
Revised: 7/17/13
STS0129