Lahore American School
Middle and High School
INITIAL REFERRAL
NOTE: This form should be completed and returned to Ramona Carter (rcarter@las.edu.pk)
To:
Ramona Carter (Learning Support)
From:
Date:
Student Name:
Grade:
Age:
NOTES:
Complete and attach the prior intervention checklist (required), supporting data and
samples of student work (if applicable) before submitting the referral.
Referring teacher MUST contact the parent/guardian to discuss concern (s) prior to
submitting the referral.
Date of contact_________________
Who made contact ______________
Reasons for Referral: Check all that apply:  Attendance  Health Behavior  Academics
Comments:
_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Observed Behaviors:
PRIOR INTERVENTIONS CHECKLIST
Please indicate the date_____________ and parent/guardian ____________________ you
spoke to regarding student.
Please indicate what types of interventions you have tried with this student and when:
1. Spoke to student privately after class.
• Explained class rules and expectations
• Explained concerns
*2. Gave student help after class/school.
Date
Outcome
___________________
___________________
___________________
3. Changed student’s seat
___________________
4. Provided differential instruction/assignments.
___________________
5. Held conference with parent in school.
___________________
6. Sent home notices regarding behavior/school work.
___________________
7. Arranged an independent study program for student.
___________________
*8. Have given student extra attention.
___________________
9. Have set up behavior management program with student.
Please attach a copy.
___________________
10. Have assigned student after school detention.
___________________
11. Have referred student to guidance/administration.
___________________
Other (Please explain)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
* Questions 2 and 8 may require additional information. Any attachment must be in the
area(s) of academics, behavior, health and/or attendance. Any attachment must be
specific, descriptive, observable, and factual.
Date Rec’d ___________