Referral Background History and Cumulative File Review
Student: _____________________________________________ Referral Date: ________________
Current School Information
: ________________________ _____________ ______________
School of Attendance Grade Level Teacher
Previous Schools Attended
: Records Status
1_____________________________________________________ 1________________________________
2_____________________________________________________ 2________________________________
3_____________________________________________________ 3________________________________
Attendance Record
: Comments on Attendance
No unusual attendance pattern ____________________________
Significant absences ____________________________
Gaps in schooling ____________________________
Previous Testing
:
Name of Test: _____________________ date of administration ________ scores: _____ _____ _____ _____
Math Rdg. Lang.
Name of Test: _____________________ date of administration ________ scores: _____ _____ _____ _____
Math Rdg. Lang.
Name of Test: _____________________ date of administration ________ scores: _____ _____ _____ ____
Math Rdg. Lang.
Previous Referrals
: Discuss Results of any Previous Referrals:
Special Education __________________________________________
Title One __________________________________________
ESL __________________________________________
Other __________________________________________
Is there evidence of possible non-academic explanations for this student's current difficulties?
Socio-economic, Environmental or Cultural disadvantage
Sensory impairment
Lack of instruction in reading or mathematics
Limited proficiency in the English language
Note: Please attach all reports or records of student grades
and student discipline records if relevant.
Other Information
: (Please provide a summary of information provided by the student's previous or current teachers,
administrators, other school staff, parents, and outside professionals.)
