ECC Learning Support Referral Form Specialists

Student Name: |Specialists name: How many years have you known this child? Concerns specific to your class: Grade/Class

Student strengths:

Please indicate the students performance in the following areas: If you feel you have no basis in which to judge please cross out the box below.

Learning
Problem Solving Motivation Follows spoken instruction Ability to stay on task Ability to work in groups Seeks help when needed Verbally expresses ideas, wants and needs Ability/readiness falls within age norms for your particular discipline

Exceeds expectation

Meets expectation

Below expectation

Well Below expectation

Behavior / Social Skills

Confidence/willing to take a risk or try something new Relationship with peers Relationship with teacher Behavior in class Organization of self/materials Transitions between activities Respects authority

Exceeds expectation

Meets expectation

Below expectation

Well Below expectation

Describe differentiated strategies/modifications already tried within the classroom: (How successful were they?)

We appreciate the time you have taken to complete this form to help us better understand the child in all areas of their learning. Do you feel you need to attend the child study meeting?