WCA Student Pre-Referral Checklist 2nd-12th Grade

WCA Student Pre-Referral Checklist 2nd-12th Grade
Student's Name*

First NameLast Name
Student's Grade *

GradeTeacher
Is this student a new student to WCA?*

YesNo
Reason(s) for referral: Speech/Language (Check all that apply)*

ArticulationVisionVoiceFluencyExpressiveHearingReceptivePragmatic Language
Reason(s) for referral: Academic Performance (Check all that apply)*

LISTENING COMPREHENSIONDifficulty understanding spoken languageDifficulty following verbal directionsORAL EXPRESSIONDifficulty expressing thoughts and ideasLimited speaking vocabularyREADINGDifficulty with comprehensionFluency concernsDecoding concernsPhonemic awareness concernsVocabulary concernsWRITTEN EXPRESSIONDifficulty with spellingDifficulty with writing mechanicsDifficulty writing a sentenceDifficulty organizing sentences and ideas
Reason(s) for referral: Check all that apply)*

ATTENTION/ORGANIZATION/ACTIVITY LEVELDifficulty beginning a taskDifficulty maintaining attentionEasily distractedLoses or forgets work and/or materialDifficulty with organizationLate for classDifficulty completing tasks/assignmentsDifficulty with changes in routineOveractiveUnderactiveInadequate note-taking skillsInadequate test-taking skillsDifficulty working independentlyMOTOR SKILLSDifficulty with functional mobilityDifficulty with gross motor tasksDifficulty with fine tasksDifficulty with coordinationMEMORYDifficulty with short term memoryDifficulty with long term memory
Reason(s) for referral: Check all that apply)*

MATHEMATICSDifficulty with number senseDifficulty with operationsDifficulty with fact fluencyDifficulty with math computationDifficulty with place valueDifficulty with math applications, reasoning, and problem solvingLack of basic foundational skillsFINE MOTOR/VISUAL MOTOR COORDINATIONDifficulty with copying from the board or book
Reason(s) for referral: Check all that apply)*

SOCIAL/EMOTIONAL/BEHAVIORALLimited eye contactIn his/her "own world"Repetitive behaviorsLacks motivationLacks self-controlEasily frustratedSudden changes in mood throughout the dayInconsistency in performanceNeeds constant approvalInterrupts and distracts classUnusually aggressive toward othersUnusually shy or withdrawnDifficulty interpreting social cuesDifficulty making and keeping friendsDoes not accept responsibility for own behaviorEasily influenced by others
Notes *
If your concern relates to learning. We would ask that you include a screenshot(s) of the student's work.

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