DESOTO PARISH SCHOOL SYSTEM
INITIAL REFERRAL TO SBLC
Submit to chairperson in order to schedule a SBLC meeting
Student __________________________ DOB__________ Sex: M F Date ________________
Grade/Subject_________________ Date of Most Recent Parent Contact: ____________________________
Reason for Referral:
1. ______ Parental Request: any parental request for an initial SBLC discussion should be honored
2. ______ Possible Gifted: Parent and/or teacher suspects that the student may have exceptional intellectual abilities
3. ______ Possible Talented: Parent and/or teacher suspects student may be talented in one of the following areas:
____ Art ________ Theater _____ Music/Vocal ______ Music/Instrumental
4. ______ Academic Concerns: _____Reading _____Math _____Written Language ____Other
Student is “at risk” for failure in at least one core subject area and the poor performance is not primarily due to
high absenteeism. The term “at risk” includes unsatisfactory grades (D’s and F’s), low standardized test scores (below the
16th percentile), or when a student demonstrates characteristics of dyslexia based upon the Dyslexia Screening, Universal
Screenings, and interventions.
5. ______ Behavior Concerns:
a. _______Attention problems are interfering with educational performance and are supported by the ADHD
screener
b. _______Aggressive and/or noncompliant behaviors that cause class disruptions (check appropriate area(s))
i. ______Student exhibits problem behavior that results in suspension from school
ii. _______Student runs away from school personnel putting his/her safety at risk
iii. _______Student threatens to hurt self or others
iv. _______Student physically harms others (hits, kicks, bites, etc.)
v. _______Student is removed from class and has received disciplinary action from administration several times per week
c. _______Withdrawn and/or anxious behaviors or signs of depression which interfere with the student’s
educational performance.
6. _______ Medical Concerns: Student has a medical condition that interferes with his/her educational
performance.
7. _______ Speech Concerns: Student failed the communication checklist.
Special Education Services: Has this student been previously evaluated and/or is the student receiving any special education
services. If yes, explain: ____________________________________________________________________________
I, ___________________________ give permission for my child, ______________________ to be
(parent)
screened/supported as needed. Date: ____________________________
