WCA Student Pre-Referral Checklist 2nd-12th Grade
Student's Name
*
First Name
Last Name
Student's Grade
*
Grade
Teacher
Is this student a new student to WCA?
*
Yes
No
Reason(s) for referral: Speech/Language (Check all that apply)
*
Articulation
Vision
Voice
Fluency
Expressive
Hearing
Receptive
Pragmatic Language
Reason(s) for referral: Academic Performance (Check all that apply)
*
LISTENING COMPREHENSION
Difficulty understanding spoken language
Difficulty following verbal directions
ORAL EXPRESSION
Difficulty expressing thoughts and ideas
Limited speaking vocabulary
READING
Difficulty with comprehension
Fluency concerns
Decoding concerns
Phonemic awareness concerns
Vocabulary concerns
WRITTEN EXPRESSION
Difficulty with spelling
Difficulty with writing mechanics
Difficulty writing a sentence
Difficulty organizing sentences and ideas
Reason(s) for referral: Check all that apply)
*
ATTENTION/ORGANIZATION/ACTIVITY LEVEL
Difficulty beginning a task
Difficulty maintaining attention
Easily distracted
Loses or forgets work and/or material
Difficulty with organization
Late for class
Difficulty completing tasks/assignments
Difficulty with changes in routine
Overactive
Underactive
Inadequate note-taking skills
Inadequate test-taking skills
Difficulty working independently
MOTOR SKILLS
Difficulty with functional mobility
Difficulty with gross motor tasks
Difficulty with fine tasks
Difficulty with coordination
MEMORY
Difficulty with short term memory
Difficulty with long term memory
Reason(s) for referral: Check all that apply)
*
MATHEMATICS
Difficulty with number sense
Difficulty with operations
Difficulty with fact fluency
Difficulty with math computation
Difficulty with place value
Difficulty with math applications, reasoning, and problem solving
Lack of basic foundational skills
FINE MOTOR/VISUAL MOTOR COORDINATION
Difficulty with copying from the board or book
Reason(s) for referral: Check all that apply)
*
SOCIAL/EMOTIONAL/BEHAVIORAL
Limited eye contact
In his/her "own world"
Repetitive behaviors
Lacks motivation
Lacks self-control
Easily frustrated
Sudden changes in mood throughout the day
Inconsistency in performance
Needs constant approval
Interrupts and distracts class
Unusually aggressive toward others
Unusually shy or withdrawn
Difficulty interpreting social cues
Difficulty making and keeping friends
Does not accept responsibility for own behavior
Easily influenced by others
Notes
*
If your concern relates to learning. We would ask that you include a screenshot(s) of the student's work.
Browse Files
Cancel
of
Submit
Should be Empty: