Student Progress Report Form

Crenshaw High School SSPT Referral
Referral Date*

YearMonthDay
Date
Time*

:HourMinutesAM/PM Option
Referring Staff Member *

First NameLast Name
Grade Level*
Parent/Guardian Name*
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 candidateDisruptiveDisrespectful to adultsFailing 2 or more classesFixed mind setHealth concernsLanguageLittle to no effortLittle to no work completedLow scores or academic performancePoor attendanceProcessing concernsPoor organzational skillsSocial/Emotional issuesOther
Does the child demonstrate any of the following? Check all that apply*

Appears sad/depressedEating problemsCries easily and/or oftenSelf-harmDisorganization/time managementHyperactivityAnxious/nervousAngers easilyBullying (Target/Aggressor)Drugs/AlcoholSexualized behaviorHallucinations/DelusionsWithdrawn/Isolates selfSleeping problemsSuicidal thoughtsDifficulties with learningLow self-esteemStruggles with social skillsAggressive behaviorDefiance towards authorityGang affiliation/tagging crewProbationNoneOther
Has positive peer social interactions?*
Has positive adult social interactions?*
Completes in-class assisgnmnets*
Completes Homework*
Participates in groups*
Attention seeking behavior*
Lacks motivation*
Follows rules*
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.
Intervention Outcomes*
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.
Should be Empty:

Crenshaw High School SSPT Referral