Crenshaw High School SSPT Referral
Referral Date
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Year
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Month
Day
Date
Time
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1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Referring Staff Member
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First Name
Last Name
Grade Level
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9th
10th
11th
12th
Parent/Guardian Name
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Primary Language at home
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Has the parent been contacted regarding your concerns?
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If yes, what was their response? Are they open to SSPT services?
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Is the student in special education?
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Background for referral Reason you are referring the student Check all that apply
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Language Assessment candidate
Disruptive
Disrespectful to adults
Failing 2 or more classes
Fixed mind set
Health concerns
Language
Little to no effort
Little to no work completed
Low scores or academic performance
Poor attendance
Processing concerns
Poor organzational skills
Social/Emotional issues
Other
Does the child demonstrate any of the following? Check all that apply
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Appears sad/depressed
Eating problems
Cries easily and/or often
Self-harm
Disorganization/time management
Hyperactivity
Anxious/nervous
Angers easily
Bullying (Target/Aggressor)
Drugs/Alcohol
Sexualized behavior
Hallucinations/Delusions
Withdrawn/Isolates self
Sleeping problems
Suicidal thoughts
Difficulties with learning
Low self-esteem
Struggles with social skills
Aggressive behavior
Defiance towards authority
Gang affiliation/tagging crew
Probation
None
Other
Has positive peer social interactions?
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Has positive adult social interactions?
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Completes in-class assisgnmnets
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Completes Homework
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Participates in groups
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Attention seeking behavior
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Lacks motivation
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Follows rules
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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
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What are the student's academic and social strengths?
Academic or Behavior concern
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What is impeding the student's learning?
Classroom Interventions and Strategies Implemented
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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
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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.
Intervention Outcomes
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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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