Crenshaw High School SSPT Referral
Referring Staff Member
Primary Language at home
Has the parent been contacted regarding your concerns?
If yes, what was their response? Are they open to SSPT services?
Is the student in special education?
Background for referral Reason you are referring the student Check all that apply
Language Assessment candidate
Disrespectful to adults
Failing 2 or more classes
Fixed mind set
Little to no effort
Little to no work completed
Low scores or academic performance
Poor organzational skills
Does the child demonstrate any of the following? Check all that apply
Cries easily and/or often
Difficulties with learning
Struggles with social skills
Defiance towards authority
Gang affiliation/tagging crew
Has positive peer social interactions?
Has positive adult social interactions?
Completes in-class assisgnmnets
Participates in groups
Attention seeking behavior
Initial Description of Concern Please Describe the student's strength's, your specific academic or behavior concerns and the interventions and strategies implemented to address these concerns. Strengths
What are the student's academic and social strengths?
Academic or Behavior concern
What is impeding the student's learning?
Classroom Interventions and Strategies Implemented
What interventions have you attempted in addressing the area of concern? Include contact with guardians and work with them on the issue. If related to behavior, refer to Behavior Instruction and Intervention Tier 1 Supports Inventory.
Intervention Frequency and Duration
When did the intervention begin? How long was it implemented? How often was it provided? Example Intervention began October 1st, it was implemented for four weeks and it was provided once a week for 30 minutes.
How did the student respond? What progress was observed?
Additional relevant information
Where the behavior occurs, relevant social/emotional information, academic history, health concerns, etc.
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