AR5123

Chino Valley Unified School District

STEP Team Referral Form
Student Name:

Birth Date:

Ethnicity:

Age:

Grade:

Parent/s:

Home/Cell Phone Number:

Work Phone Number:

Teacher:

Previous SST or STEP

Team
Dates:
ELL:
Yes
No
Number of Years:
Referred by:

Has student been retained?

Yes
No

Gender:
M

Home Language:
Referral Date:
Medical Diagnosis:

Hearing pass:
Yes

No

Overall CELDT Level:

Discipline Referrals:
Yes
Vision pass:
Yes

No
No

Current Second Step Lesson

Mark the area(s) of concern:

Academic

Behavioral

Language

Identify Student Strengths (check all that apply)

Academic Skills
Artistic
Attentive
Compassionate
Courteous
Confident
Cooperative
Coordination Skills

Creative
Enthusiastic
Hard Worker
Highly Articulate
Leadership Skills
Likes School
Listens Effectively
Optimistic

Patience
Physical Strength
Positive Social Skills
Sense of Humor
Tries/Attempts Tasks
Other
Other
Other

Specific Areas of Concern (check all that apply)

Reading
reading readiness
phonological awareness
syllabication
word patterns
word attack/structural analysis
fluency
reading comprehension

Writing
handwriting (control, attend
to/recall shapes & processes)
spelling (phonetics, linguistic
rules, irregularities, reading &
decoding)
expression (composition)
fluency

Math
number sense
memory & strategy
comprehension for: conceptual
understanding & word problems
language/communication skills
(read, write, discuss)

Behaviors of Concern (check all that apply)

physical aggression
verbal aggression
class disruption
playground infractions

appears sad or withdrawn

appears anxious
frequent absences
physical symptoms

Other:
Other:

Other:
Other:

Replaces Form C

control of attention
distracted
task completion
loses interest quickly
impulsive
Other:
Other:

Page 1 of STEP Intervention Plan

social skills
friendships
peer conflict
plays by self
Other:
Other:

6-16-2016