• TEACHER/COUNSELOR REPORT

    (To be completed by a teacher or counselor who is familiar with the student's classroom performance)
  • Date of Birth
  • POSITIVE CHARACTERISTICS (Check all that apply)

  • GENERAL CONCERNS ABOUT STUDENT'S PERFORMANCE (Check all which apply)

  • Attendance Information

  • Good Attendance:
  • Punctual:
  • Frequently Absent:
  • Frequently Tardy:
  • Did the student attend kindergarten?
  • Has the student been retained?
  • Academic Skills
    Rows

  • TEACHER REPORT OF GENERAL EDUCATION INTERVENTION

  • Accommodations provided: (check all that apply)

  • Research Based Interventions: e.g. Reading Mastery, Corrective Reading (attach assessment data)
  • Additional Interventions: e.g. Tutoring, Remediation Specialist, Title I, Individualized Instruction, School Counseling, Behavior Plan

  • TEACHER REPORT OF ACADEMIC DIFFICULTY

  • READING ASSESSMENT (To be completed by the student's reading teacher):

  • Degree of reading difficulty:
  • None Problems observed/identified in the student's reading (Check as applicable):

  • MATHEMATICS ASSESSMENT (To be completed by the student’s mathematics teacher):

  • Degree of mathematics difficulty:
  • Problems observed/identified in the student’s mathematics (Check as applicable):

  • WRITTEN EXPRESSION ASSESSMENT (To be completed by the student’s language arts teacher)

  • Degree of writing difficulty:
  • Problems observed/identified in the student’s written expression (Check as applicable):

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  • Should be Empty: