Student Support Plan
© Communities In Schools, Inc.—subject to usage agreement
Table of Contents
I.
Student Support Plan Checklist ............................................................................................................. 4
II.
Student Profile ...................................................................................................................................... 5
III.
Student Assessment .......................................................................................................................... 6
IV.
Risk Factor Assessment: Check All That Apply .................................................................................. 7
V.
Student Assets & Strengths: Check All That Apply ............................................................................... 8
VI.
Student Supports .............................................................................................................................. 8
VII.
Student Plan Calendar....................................................................................................................... 9
VIII.
Student Meeting Log....................................................................................................................... 11
IX.
Monitoring and Adjusting Report ................................................................................................... 12
X.
Year End Student Review .................................................................................................................... 13
XI.
Year End Review Checklist .............................................................................................................. 14
2
© Communities In Schools, Inc.—subject to usage agreement
3
© Communities In Schools, Inc.—subject to usage agreement
Student Support Plan for <<Student NAME>>
I.
Student Support Plan Checklist
Intake/Assessment
Referral Date:
Referral Source:
<<Date>>
<<Source>>
Initial Meeting with
Student:
<<Date>>
Parent/Guardian
contacted on:
<<Date>>
Parental/Guardian
consent received on:
<<Date>>
Student Assessment
completed on:
<<Date>>
Planning
Student Support Plan created
on:
<<Date>>
Student Assessment and Student
Plan completed in CISDM:
<<Date>>
Notes:
Ongoing Review:



Meet with individual student at least once/month to monitor and assess progress
Track identified standard metric(s) and student progress every grading period
Use the table below to track formal student check-in meetings - if they do not happen, please give a
brief description why
Monthly Check-ins: 1st
Quarter – List Dates
<<Date>>
Monthly Check-ins: 2nd
Quarter – List Dates
<<Date>>
Monthly Check-ins: 3rd
Quarter – List Dates
Monthly Check-ins: 4th
Quarter – List Dates
<<Date>>
<<Date>>
Site Coordinator: ___________________________________________________________________
School: ____________________________________________ Date: __________________________
**The information in this plan is confidential. If found, please return to the main office or the CIS site coordinator office.
4
© Communities In Schools, Inc.—subject to usage agreement
Student School ID#: _____________________________________________ School Year: ______/______
II.
Student Profile
Personal Information:
DOB:
Age:
Gender:
Languages Spoken:
Race/Ethnicity:
☐M ☐ F ☐ Other: _______________________
☐White Non-Hispanic ☐Hispanic/Latino ☐Black/African American ☐ Asian/Pacific
Islander ☐American Indian/Alaska Native
☐Multi-Racial: ______________________☐Other: _____________________
Has student been
☐Yes ☐No When: ______________________
involved with CIS before?
School-Related Information:
Student School ID #:
Grade:
Home Teacher:
Program Participation:
☐Free/Reduced Price Lunch ☐English Language Learner ☐Special Education
☐Migrant Program ☐SNAP/Food Stamps ☐TANF ☐WIC
☐ Other: Please describe: _____________________________________________
Family Information:
Parent/Guardian Name:
Phone:
Email:
Living Situation:
❑ Both Parents ❑ Single parent Female/Male ❑ Other Relative: __________________
❑Foster care/group home ❑ Shelter ❑ Homeless ❑Alone ❑Unknown
❑Other:________________________________________________
____ # of family members in household ____ # of non-family in household
Sibling Name
Age
Grade
School
Notes
Served
by CIS?
5
© Communities In Schools, Inc.—subject to usage agreement
Student School ID#: _____________________________________________ School Year: ______/______
III. Student Assessment
Date of Initial
Assessment:
Pre-CIS
Data (if
applicable)
Most
Recent
Data
Goal
1st
Review
Date:
______
______________
Attendance %
(days
present/total)
2nd
Review
Date:
______
3rd
Review
Date:
______
4th
Review
Date:
______
End of
Year
Progress
Overall GPA
Math Grade
Reading Grade
Suspensions – ISS
and OSS
Credit completion
Standardized
Testing - Math
Indicate test used & level
of proficiency
Standardized
Testing - Reading
Indicate test used & level
of proficiency
Other:
Other:
EOY Progress
Indicator
-2 = Significant decline
-1 = Slight decline
0 = No progress/
maintained
+1 = Slight
improvement
+2 = Significant
improvement
Notes:
6
© Communities In Schools, Inc.—subject to usage agreement
Student School ID#: _____________________________________________ School Year: ______/______
IV. Risk Factor Assessment: Check All That Apply
Individual Student Risk Factors
Aggressive behavior
Anti-social behavior
Emotional/mental health concerns
Excessive after-school work hours
Excessive social activity out of school
Identified
☐
☐
☐
☐
☐
Health/medical concerns (e.g., ADHD,
ADD, obesity)
☐
High risk behavior (e.g., alcohol, drugs,
sexually active)
☐
High risk peer groups (e.g., gangs,
delinquent youth, bullies)
☐
Involvement with the juvenile justice
system (e.g., previous arrests, detention)
☐
Lack of effort in school
Learning disability (e.g., dyslexia)
Low commitment/poor attitude toward
school
Low educational expectations
No extracurricular activities
Not living with both natural parents
Over age for grade/retained in grade
Poor academic performance
Poor attendance/truancy
Pregnant or parenting teen
☐
☐
☐
☐
☐
☐
☐
Family Risk Factors
Family disruption/stress (e.g., divorce, death,
incarceration, homelessness)
Family history of mental health problems
Favorable attitudes toward problem behaviors (e.g.,
skipping school, ATOD use, bullying)
High family mobility
Lack of contact/engagement with school
Lack of family conversation about school/education
Lack of parental supervision/discipline
Large number of siblings
Low educational expectations
Low socioeconomic status
Parent(s) with low education level (e.g., high school
dropout, GED)
Sibling has dropped out of school
Social isolation of family
Other:
Other:
Identified
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Notes:
☐
☐
☐
School misbehavior (e.g., suspensions,
expulsions, classroom misconduct)
☐
Other:
☐
Other:
☐
7
© Communities In Schools, Inc.—subject to usage agreement
Student School ID#: _____________________________________________ School Year: ______/______
V. Student Assets & Strengths: Check All That Apply
Support
Family support
Identified
☐
Positive family communication
Other adult relationships
Caring neighborhood
☐
☐
☐
Caring school climate
☐
Parent involvement in schooling
Youth as resources
Service to others
☐
☐
☐
Homework Completion
Bonding to school
Neighborhood boundaries
Adult role models
☐
☐
☐
Positive peer influence
High expectations
☐
☐
Youth programs
Religious community
Time at home
☐
☐
Positive Values
☐
Equality and social justice
Integrity
☐
☐
Honesty
☐
Responsibility
☐
☐
Social Competencies
Planning and decision making
Interpersonal competence
Cultural competence
Resistance skills
☐
☐
☐
☐
Peaceful conflict resolution
Constructive Use of Time
Creative activities
☐
☐
Reading for pleasure
☐
School boundaries
Identified
☐
Restraint
Boundaries & Expectations
Family boundaries
School engagement
Caring
☐
Safety
Achievement motivation
☐
Empowerment
Community values youth
Commitment to Learning
☐
Positive Identities
☐
☐
☐
☐
Personal power
Self-esteem
Sense of purpose
Positive view of personal future
☐
☐
☐
☐
VI. Student Supports
*Each student must have at least one goal/support that addresses attendance, behavior or
course performance needs.
8
© Communities In Schools, Inc.—subject to usage agreement
Student School ID#: _____________________________________________ School Year: ______/______
Supports to be Provided
Goal:
Support/Program:
Frequency of
Tier of Support
Participation:
☐ Tier I
☐ Tier II
☐ Tier III
☐ Tier I
☐ Tier II
☐ Tier III
☐ Tier I
☐ Tier II
☐ Tier III
☐ Tier I
☐ Tier II
☐ Tier III
☐ Tier I
☐ Tier II
☐ Tier III
☐ Tier I
☐ Tier II
☐ Tier III
☐ Tier I
☐ Tier II
☐ Tier III
☐ Tier I
☐ Tier II
☐ Tier III
Notes:
VII. Student Plan Calendar
Indicate all supports student is receiving and any regular check-ins with the site coordinator.
Monday
Tuesday
Wednesday
Thursday
Friday
9
© Communities In Schools, Inc.—subject to usage agreement
Student School ID#: _____________________________________________ School Year: ______/______
Example Week:
Afterschool
volunteer
program at
Senior Center
Student Check-in:
handout
attendance
incentive if
attendance has
improved
Big Brothers Big Sisters
Before school sports
program
Afterschool
volunteer program
at Senior Center
Food
backpack
program
Small group
behavior
session
Please list any additional supports that do not fit a set schedule
10
© Communities In Schools, Inc.—subject to usage agreement
Student School ID#: _____________________________________________ School Year: ______/______
VIII. Student Meeting Log
Meeting Date
Did you
review
goals and
progress?
Did you
discuss
current
supports?
Notes:
Next Steps:
11
© Communities In Schools, Inc.—subject to usage agreement
Student School ID#: _____________________________________________ School Year: ______/______
IX. Monitoring and Adjusting Report
Action
Review Student Goals & Meeting Log
Update Student Assessment & CISDM with current school data
Review Student Supports and discuss any potential adjustments with Student Support
Team
Solicit feedback from principals, teachers, school counselors, service providers, volunteer
tutors, etc. regarding student progress
Modify Student Support Plan, as needed, to drive better student outcomes
Document student progress in CISDM case progress area
Update any other appropriate sections in CISDM
List dates you reviewed & adjusted Student Support Plan
Completed
☐
☐
☐
☐
☐
☐
☐
List dates you updated CISDM with student’s data
Notes:
12
© Communities In Schools, Inc.—subject to usage agreement
Student School ID#: _____________________________________________ School Year: ______/______
X.
Year End Student Review
Date of Year End Review:
Dates Student was
involved with CIS
______________
Start
End
/
/
Standard Metrics
Goal
End of Year
Progress
Attendance %
(days present/total)
Overall GPA
Math Grade
Reading Grade
Suspensions – ISS and OSS
Credit completion
Standardized Testing - Math
Standardized Testing - Reading
Notes from School Data:
What Was Student Outcome at Year End Review?
Promoted
Retained
Transferred within district - Where:
Transferred outside district - Where:
Out-of-state
Graduated
GED
Dropped out - Date:
Expelled
Incarcerated
Deceased
College:
Career (non-military):
Military
Other
Should student receive CIS services next year?
☐Yes
☐No
☐Unsure
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Notes:
☐N/A
13
© Communities In Schools, Inc.—subject to usage agreement
Student School ID#: _____________________________________________ School Year: ______/______
XI. Year End Review Checklist
Action
Review Student Goals & Case Log
Update Student School Assessment with EOY data
Fill out Year End Student Review
Make any final notes to student supports and identify adjustments if student will be served
by CIS next year
Solicit feedback from principals, teachers, school counselors, service providers, volunteer
tutors, etc. regarding EOY status of student
Input any and all changes into CISDM
Complete EOY for student in CISDM
If student planning to attending a different school where CIS supports are provided,
ensure proper protocol is in place to hand-doff student
Notes:
Completed
☐
☐
☐
☐
☐
☐
☐
☐
14
© Communities In Schools, Inc.—subject to usage agreement