WCA Student Pre-Referral Checklist ECE- 1st Grade
Student's Name
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First Name
Last Name
Student's Grade
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Grade
Teacher
Is this student a new student to WCA?
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Yes
No
Reason(s) for referral: Speech/Language (Check all that apply)
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Articulation
Vision
Voice
Fluency
Expressive
Hearing
Receptive
Pragmatic Language
None
Reason(s) for referral: Academic Performance (Check all that apply)
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Difficulty understanding spoken language
Difficulty following verbal directions
Does not use words yet
Difficulty labeling objects, naming people
Difficulty expressing thoughts and ideas
Limited speaking vocabulary
Difficulty naming pictures -
Difficulty identifying colors, shapes
Difficulty listening to a book read orally
Difficulty with letter/word recognition
Difficulty with phonemic awareness, phonics
Difficulty with comprehension (informational, literary text)
Fluency concerns
Difficulty with spelling
Difficulty with writing mechanics
Difficulty writing a sentence
Difficulty organizing sentences and ideas into meaningful paragraphs
None
Reason(s) for referral: Check all that apply)
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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
Difficulty with functional mobility
Difficulty with gross motor tasks
Difficulty with fine tasks
Difficulty with coordination
Difficulty feeding
Difficulty dressing
Difficulty sleeping
Difficulty toileting
Difficulty with short term memory
Difficulty with long term memory
Difficulty identifying colors, shapes
None
Reason(s) for referral: Check all that apply)
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MATHEMATICS
Difficulty with 1:1 correspondence ❑ Difficulty with rote counting
Difficulty with number recognition
Difficulty with math computation
Difficulty understanding numeration concepts
Difficulty with math applications, reasoning, and problem solving
None
FINE MOTOR/VISUAL MOTOR COORDINATION Difficulty grasping objects
Difficulty stringing beads
Difficulty holding crayon/pencil
Difficulty imitating shapes
Difficulty copying shapes
Difficulty with paper/pencil tasks
Difficulty writing name
Difficulty turning pages in a book
Difficulty with buttons, snaps
Difficulty with copying from the board or book
None
Reason(s) for referral: Check all that apply)
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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
None
GROSS MOTOR/MOTOR PLANNING
Difficulty Walking
Difficulty Jumping
Difficulty Climbing
Difficulty Throwing
None
Notes
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If your concern relates to learning. We would ask that you include a screenshot(s) of the student's work.
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