IAT REFFERAL FORM
Carlin Springs 2013-2014
Date of Referral: ___________________
Classroom Teacher: ________________
Date of Birth: _____________________
Native Language: ____________________
Referring Teacher: ___________________
Name of Child: __________________________
Grade: _____________________________
Translator? Yes or No What language?___________
Current Instructional Levels (Please note benchmarks where applicable)
Course
Reading
Writing
Math
Science
Instructional
Levels
Social Studies
Areas of STRENGTH/CONCERN relative to child’s constellation of abilities:
(Please indicate a “S” for Strength OR a “C” for Concern)
Note: All areas do not need to be marked just areas relevant to student)
Reading:
____ Phonemic Awareness: The ability to hear and manipulate sounds in
words.
____ Alphabetic Principle: The ability to associate sounds with letters and use
these sounds to form words.
____ Fluency with Text: The effortless, automatic ability to read words in
connected text.
____ Vocabulary: The ability to understand (receptive) and use (expressive)
words to acquire and convey meaning.
____ Comprehension: The complex cognitive process involving the intentional
interaction between reader and text to convey meaning.
____ Other (Please explain):
Writing:
____ Fluency
____ Word order
____ Spelling
____ Volume/Production
____ Quality of content
____ Handwriting
____ Other (Please explain):
Math:
____ Calculation
____ Fact fluency
____ Mathematical Problem-Solving
____ Other (Please explain):
Other:
Social/Emotional:
____ Makes and keeps friends
____ Demonstrates effective advocacy skills
____ Offers support to others
____ Involved in extracurricular activities
____ Tantrums
____ Work Refusal
____ Bullying Behavior
____ Fatigued/Lethargic
____Argumentative
____ Poor Frustration Tolerance
____ Other (Please Explain):
Attendance:
____ Arrives on time
____ Arrives late
____ Good Attendance
____ Poor Attendance
____ Other (Please explain):
Academic Readiness:
____ Organization
____ Participation
____ Following multi-step directions
____ Concentration
____ Retention of information
____ Homework completion
____ Ready to work
____ Other (Please explain):
Current Support Services
__ESOL
__HILT
__Tutoring/Mentor
__Nurse
__Title I Reading
__Title 1 Math
__After School Tutoring
__YES Club
__Reading Recovery __ Ear-obics
__School Based DHS
__DHS
__Phonographix
__Other (Please Explain)____________________________________
Consultations with:
__Counselor
__Previous Teacher(s)
__Nurse
__School Based DHS
__Counseling
__My Reading Coach
__Private Therapy
__ESOL/HILT Teacher __Grade Level Team
__Reading Teacher
__School Admin.
__Parents/Guardian
__Resource Specialist
__G/T Teacher
__Pupil Personnel (Social Worker, Clinical Psych/School Psych, etc...)
__Other (Please Explain)____________________
Strategies/Accommodations/Interventions Attempted:
__Modified Workload
__Use of Computer
__Directions Repeated
__Preferential Seating
__Study Guides
__Behavior Plan/Contract
__Dictation
__Questions Read
__Counseling (w.______)
__Small Group Instruction
__Agenda Book Check
__Oral testing
__Additional Think Time
__Peer Learning
__Extended Test Time
__Individual Instruction
__Visual Cues/Pictorial Cues
__Graphic Organizers
__Visual Models
__Manipulatives
__Study Schedule