Child Study/RTI Problem Solving Team
Student Referral
Whitesville Central School
Referral Information
Student:
DOB:
Grade:
Home:
Parent:
Work:
Classroom Teacher:
Referral Date:
Referring Person:
I. Parent Contact
Have you explained the concern in detail to the parents?
a. If not, please do so before completing this form
b. If you have, what was the parents’ response to this concern? Please describe below.
c. Prior to the CST meeting, the referring teacher MUST conduct the parent interview via
telephone. This will continue to help build the parent/school relationship and gain additional
parent support. Parent Interview forms can be obtained from the office.
II. Social
Is the concern social? If so, have you contacted the school counselor?
a. If not, please do so before continuing with this form?
b. If you have, what interventions were tried and how successful were they?
Child Study/RTI Problem Solving Team
Student Referral
Whitesville Central School
III. Strengths
Please list the student’s strengths:
IV. Areas of Concern
Please circle the area of concern and check any specifics that apply:
Reading:
Writing:
Math:
Behavior:
___Phonemic
Awareness
___ Sentence
Structure
___Number and
Numeration
___ Distractibility
___ Hyperactivity
___Phonics
___ Topic Focus
___Operations
___Comprehension
___ Paragraph
Structure
___Measurement
___ Peer
Relationships
___Patterns/Functions
___ Emotionality
___ Essay Structure
___Estimation/Prediction
___ Off-Task
Behavior
___ Organization
___Problem Solving
___ Organization
___ Sequencing of
Thought
___Modeling/Multiple
Representation (charts,
graphs)
___ Avoidance
___Fluency
___ Grammar
___Vocabulary
___ Main
Idea/Supporting
Details
___ Aggression
___ Bullying
___ Attention (lack
of/seeking)
___ Motivation
___ Defiance/
Noncompliance
Child Study/RTI Problem Solving Team
Student Referral
Whitesville Central School
V. Concern
Please describe the exact nature of your concern:
VI. Goals
What are your ultimate goals for this student?
VII. Grades
Please indicate the student’s current grades/levels in each of the following areas:
Math:
Science:
Reading:
AIMS WEB:
Writing:
Social Studies:
STAR Reading Level:
Leveled Reader:
below
on
above
Child Study/RTI Problem Solving Team
Student Referral
Whitesville Central School
VIII. Academic (Tier 1)
If the concern is academic, what strategies have you tried, and how long did you implement the
strategy? How successful were they?
***Please provide Universal/Tier II documentation form with time frame and include student
work samples as well.
Strategy:
Implementation of time frame (days, weeks, months):
Assessment of strategy (student work, rubrics, documentation logs, etc.):
IX. Social
Please indicate whether the student matches the following descriptions:
Respectful
Courteous
Cooperative
Friendly
Able to make and
share friends
Able to follow
directions
Able to follow
rules
Easily swayed by
peers
Neat in
appearance
Neat with school
work
Self-confident
Self-controlled
Works
independently
Willing to ask for
help
Displays
appropriate emotions
Demonstrates
“common sense”
Social Concerns:
Accepts
consequences
Self-motivated
Willing to
participate
Child Study/RTI Problem Solving Team
Student Referral
Whitesville Central School
X. Other Academic and Behavioral Strategies (Tier I)
Please indicate the interventions, which have been implemented and describe their
effectiveness.
Strategy
Effectiveness
Sent a note home to the parent(s).
Spoke to parent(s) on the phone.
Held a parent conference.
Explained concerns with the student.
Gave the student extra help.
Change the student’s seat.
Adapted materials.
Reduced the number of homework items.
Used the highlighter to identify key words or
phrases.
Provided a peer tutor.
Adapted tests.
Student followed along at his/her seat while
the test was read orally.
Gave more frequent quizzes.
Allowed more time to take quizzes.
Allowed to answer quiz/test orally.
Established and posted classroom rules.
The parent signed homework assignments.
Conferred with Reading/Math Specialist
.
Implemented a behavior management plan.
Consulted the school counselor.
__ other
.
XI. Services
Please indicate any consistent services the student currently receives:
Service
Provider
Service
Speech
OT/PT
Counseling
/21st Century
RtI Reading
Big Brother, Big
Sister
AIS Math
___ Peer Works
__ other
Provider
XII. Additional Information
Has the student ever been retained? Y
N
If yes, at which grade?
How many days has the student been absent this year?