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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
*
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
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