Sample Forms for Child Study Team

Child Study Team

Name of Student __________________________ Previous Referral yes____ Date _________
Referring Teacher _________________________
______________no ___
Date initiated ___________________________ Date File is Completed _________________

A Child Study Team is called for when it appears that a student is not reaching full potential in the current educational or classroom setting. The purpose is to bring together a team of professionals to observe, gather information, look for ways to enhance the child's educational experience, and at times to make a special education referral.

A packet of materials is developed to help gain information about the student. When the following forms have been compiled, the team can meet and discuss solutions.

_____ Request for assistance
_____ Letter to parents
_____ Observations
_____ Health Status of child
_____ Social History
_____ School History
_____ Work samples

Request for Assistance
Sample

Referral by ____________________ Date ________________
   
Student name ________________________ Student Date of Birth ______________
School ________________________ Grade __________________________

1. Academic concern:

____ Health ____ Hearing ____ Vision ____ Coordination
____ Seizures ____ Speech ____ Articulation ____ Vocabulary
____ Listening skills ____ Math ____ Spelling ____ Slow processing
____ Delays ____ Memory ____ Writing ____ Language - ESL
____ Disorganized ____ Unfocused ____ Self stims ____ Work not done

Behavior issues:

____ Off task ____ Talking out ____ Out of seat ____ Truancy
____ Aggressive ____ Passive ____ Crying ____ Foul language
____ Moody ____ Bullying ____ Hyperactive ____ Raging temper

Social Issues:

____ Few or no friends ____ Attention seeking ____ Name calling ____
____ Gossips or scandalizes ____ Low esteem ____ Fears others
____ Can't follow rules ____ Lacks empathy ____ Withdrawn
____ Can't take risks ____ Anxious ____ Compulsive

Other:

Please give graphic examples of time and continuity for those things noted.

 

Has the student been diagnosed with a condition previous to this study?

 

Is English the student's primary language? ______ yes _______ no
What is the primary language spoken in the home? _________________________

What are the areas of success:

Interventions to date:

Dates of parent contacts with respect to the concern:

Letter sent to parents yes _________ no ____________ Date _________________

Sample Letter

Dear _________________

Jeremy is having some difficulty in school. You will recall our conversations on _________ and _____________. We want his academic time to be well spent and believe it is important to review his successes and look for ways to enhance his educational progress.

He is being referred to the Child Study Team to take a comprehensive look at his needs. We will be talking with you soon. We will plan to talk with you about your son's experiences at home, in other schools, and in social situations. We will also want to know about his health and activities at home.

If you have any questions about the Child Study Team, please feel free to contact me.

Sincerely,
Classroom Teacher

 

Response from parents: Date:

________________________
________________________

Health Status of Student
Sample

Vision checked _______ Near _____________Far ________ Color _______
Prescription glasses or other noted conditions __________________________
Hearing checked _______________________
Hearing aid or other noted conditions _________________________________
Speech problems _________________________________________________

Developmental status - height ___________ weight ___________ Norm ____

Illnesses noted __________________ Immunizations _______ yes _______ no

Impression of student health _________________________________

Note of parental concerns with respect to health __________________

Note of parent health issues __________________________________

Visits to Nurse this year _____________________________________

Attendance _______________________________________________

School History Sample
Achievement Test Record

IQ - Name of test _____________________________ Date ________________
Achievement scores  
Reading level ____________________________ Math _______________
Adaptive behavior _________________________  
Other tests given  

Previous Placements

Intervention Team Meeting

Describe nature of concerns:

Dates of occurrences or observation of student issues:

Goals to address concerns:

Actions to be taken:

Description Person in charge Date initiated

1.

2.

3.

4.

Review of intervention:

Date: ________________________________

Social History Sample

Person interviewed __________________ Person interviewing _____________
Name of child ___________________ Date of interview _______________

Date of Birth    
Birth size and weight Apgar rating Prematurity
Trauma Natural or Caesarian Birth Trauma
     
Parents Step Parents  
Additional adults of significance Extended family  
Siblings (including step sibs if known) Place in family (eldest, etc.)  
     
Address Phone number  
Years at location Family origin  

Health History

Family History

School History