Request for Student Support -

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Request for Student Support

Hidden
School Year
- 2021/2022
- 2020/2021
- 2019/2020
- 2018/2019
Teacher's Name*
First Last
Child's Name*
First Last
Grade*
Child's Date of Birth
MM slash DD slash YYYY
Reason for request
Describe the specific behavior and the academic or social impact of the behavior
Strategies implemented
Please describe strategies you have used in the classroom
Outreach
Please describe your outreach to parents, other school staff, providers and administrators
What has been effective so far?*
Please describe this students's strengths
What are you hoping will result from this intervention?
Please mark all that apply to the student
- does not accept correction about work
- does not ask for help when needed
- easily frustrated
- lacks confidence
- withdraws or lashes out when faced with a problem or frustration
- does not cope well with stress
- cries frequently
- displays involuntary movements or noises
- transitions, changes in activity and & unstructured times are difficult
- clings to adults/teachers
- appears to be a "loner"
- overly timid or shy
- disruptive behaviors
- often breaks rules
- often breaks objects
- provokes or aggravates others
- physically aggressive/fights
- does not comply readily with teacher or adult requests
- defiant/challenges authority
- temper tantrums
- irritable/moody
- requires constant supervision
- blames others/ difficulty accepting responsibility for behavior
- restless fidgety
- talks excessively
- behaves compulsively or without self control
- high activity level/difficulty remaining in seat when expected
- does not seem to learn from past consequences of behavior
- has difficulty waiting his/her turn
- does not work well as a member of a group
- often uncooperative with adults
- difficulty interacting appropriately with peers
- often blurts out, interrupts, talks at inappropriate times
- does not have friends at school
- is often in conflict with peers
- engages in bullying behavior
- often feels bullied
- often feels left out
- has a difficult time managing routines
- is often late for school
- is often absent to school
- has difficulty sharing ideas in a group
- struggles in mathematics
- struggles in reading
- struggles in writing
- struggles in
- other
Evidence of Learning Issues: Academic (please bring hard copy)
- running record
- hand writing samples
- writing samples
- spelling tests
- math facts and word problem samples
- other
File
Max. file size: 50 MB.
Evidence of Learning Issues: Behavioral
- video
- photograph
- anecdotal records
- ABC analysis
- High Meadow tally chart
- other
Additional Notes:
Hidden
Follow Up Notes