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  • ECC Referral Form

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    Francis A. Buenaventura
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    ECC Learning Support referral form. Student's current level of instruction in English / French / Writers' Workshop? Yes / no Years of instruction in French / English at home. Has child ever received outside evaluation? Yes / no Please state evaluation. List three strengths of the student: 2. List in the table below up to three specific reasons for this referral: Concerns Data / evidence Strategies tried 3. Please indicate the student's performance in the following areas: Learning Exceeds Expectation Meets Expectation below

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    ECC Learning Support referral form. Student's current level of instruction in English / French / Writers' Workshop? Yes / no Years of instruction in French / English at home. Has child ever received outside evaluation? Yes / no Please state evaluation. List three strengths of the student: 2. List in the table below up to three specific reasons for this referral: Concerns Data / evidence Strategies tried 3. Please indicate the student's performance in the following areas: Learning Exceeds Expectation Meets Expectation below

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    92 views2 pages

    ECC Referral Form

    Uploaded by

    Francis A. Buenaventura
    ECC Learning Support referral form. Student's current level of instruction in English / French / Writers' Workshop? Yes / no Years of instruction in French / English at home. Has child ever received outside evaluation? Yes / no Please state evaluation. List three strengths of the student: 2. List in the table below up to three specific reasons for this referral: Concerns Data / evidence Strategies tried 3. Please indicate the student's performance in the following areas: Learning Exceeds Expectation Meets Expectation below

    Copyright:

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    ECC Learning Support Referral Form

    Student Name: ______________________

    Grade/Class: __________________

    Date of Birth: (dd/mm/yy) _____________

    Date of Referral: _______________

    Date of entry to ISB: ___________

    Referee: ______________________

    Names of Specialists: _____________________________________________________


    _______________________________________________________________________
    Currently attending:
    English/ French /Writers Workshop? Yes/No
    Level and Teacher: _______________________________________________________
    Years of instruction in English: _____________________________________________
    Languages spoken at home: ________________________________________________
    Has the child had a Psycho Educational or any other outside evaluation? Yes/no
    Please state evaluation. ____________________________________________________
    Has the child ever received Literacy/Math Support, Learning Support, or any outside therapy at ISB
    or previous school? Yes/no
    What support has the child received and for how long? ___________________________
    ________________________________________________________________________
    Are there medical needs? State needs. ________________________________________
    ________________________________________________________________________
    Is the child currently on any medication? State medication and purpose.
    ________________________________________________________________________
    1. List three strengths of the student:

    2. List in the table below up to three specific reasons for this referral:
    Concerns

    Data/evidence

    Strategies tried

    3. Please indicate the students performance in the following areas:

    Learning

    Exceeds
    Expectation

    Meets
    Expectation

    Below
    Expectation

    Well Below
    Expectation

    Exceeds
    Expectation

    Meets
    Expectation

    Below
    Expectation

    Well Below
    Expectation

    Problem Solving
    Motivation
    Follows written, pictorial, or boardmaker
    instruction (indicate which)
    Follows spoken instruction
    Completion of tasks
    Ability to stay on task
    Ability to work in groups
    Seeks help when needed

    Behavior / Social Skills


    Self esteem
    Relationship with peers
    Relationship with teacher
    Behavior in class
    Behavior out of class
    Organization of self/materials
    Attendance
    4.

    Please gather all requested information from the checklist and add brief comments when
    appropriate to clarify directions or prompts.
    Attach this form to your Learning Support Referral Checklist and work samples and give to
    Loretta Stanley.

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