AR5123

Chino Valley Unified School District

STEP Team Referral Form
Student Name:

Birth Date:

Gender:

Ethnicity:

Age:

Grade:

Parent/s:

Home/Cell Phone Number:

Work Phone Number:

Teacher:

Previous SST or STEP

Team
Dates:
ELL:
Yes
No
Number of Years:

Has student been retained?

Yes
No

Referral Date:

Referred by:

Medical Diagnosis:

Hearing pass:
Yes

Discipline Referrals:
Yes
Vision pass:
Yes

Home Language:

Behavioral

Overall CELDT Level:

No
No

Current Second Step Lesson

Mark the area(s) of concern:

Academic

No

Language

Identify Student Strengths (check all that apply)

Academic Skills
Artistic
Attentive
Compassionate
Courteous
Confident
Cooperative
Coordination Skills

Creative
Enthusiastic
Hard Worker
Highly Articulate
Leadership Skills
Likes School
Listens Effectively
Optimistic

Specific Areas of Concern (check all that apply)

Patience
Physical Strength
Positive Social Skills
Sense of Humor
Tries/Attempts Tasks
Other
Other
Other

Reading
reading readiness
phonological
awareness
syllabication
word patterns
word attack/structural
analysis
fluency
reading comprehension

Math
number
sense
memory &
strategy
comprehension for: conceptual
understanding & word problems
language/communication skills
(read, write, discuss)

Writing
handwriting
(control, attend
to/recall shapes & processes)
spelling (phonetics, linguistic
rules, irregularities, reading &
decoding) expression
(composition)
fluency

Behaviors of Concern (check all that apply)

physical aggression
verbal aggression
class disruption
playground infractions

appears sad or
withdrawn appears
anxious frequent
absences physical
symptoms

control of attention
distracted task
completion loses
interest quickly
impulsive
Other:

Other:
Other:

Replaces Form C

Other:
Other:

Page 1 of STEP Intervention Plan

social skills
friendships
peer
conflict
plays by
self

Othe
r:

Other:
Other:

6-16-2016