Elementary Referral Form - Teacher
We would appreciate your candid evaluation of in the below areas. The student's parent(s)/legal guardian(s) are aware that we've requested an evaluation of their child and that your comments will be held confidential. Thank you for your time and effort.
Child's Name
First Name
Last Name
I have known this child for:
Please rate this applicant on the following characteristics, if applicable:
Social Development
Beyond expectations for age
Age-appropriate
Making progress
Not applicable/not witnessed
Works well in group activities
Gets along well with peers
Respects the rights of others
Is honest
Enters new activities enthusiastically
Solves problems without verbal or physical aggressiveness
Is cooperative with classmates and teachers
Is dependable
Shows leadership qualities
Takes part in class discussions
Interacts well with peers in structured activities
Emotional Development
Beyond expectations for age
Age-appropriate
Making progress
Not applicable/not witnessed
Speaks for behaves with minimal impulsivity
Accepts responsibility for own actions and mistakes
Accepts limits imposed by adults
Self-monitors behaviors
Work Habits
Beyond expectations for age
Age-appropriate
Making progress
Not applicable/not witnessed
Follows directions
Uses time wisely
Accepts and completes independent work
Attends school regularly
Listens attentively
Uses classroom materials responsibly
Follows established classroom procedures
Is enthusiastic about learning
Shows organization and planning skills
Accepts and follows through on suggestions for improvement
Physical Development
Beyond expectations for age
Age-appropriate
Making progress
Not applicable/not witnessed
Has normal gross motor control
Has normal fine motor control
Participates in active play, sports, or games
To your knowledge, has this child received any evaluations, additional resources, or special services? This may include including speech therapy, occupational therapy, behavioral difficulties, developmental delays, etc.
Yes
No
Other
If yes, please describe:
Based on your experience, is your perception of this child consistent with the parents' perception?
Name of person completing this form:
First Name
Last Name
Name of school/care facility:
School phone number
Name of class or grade level
Submit
Should be Empty: