Child Study Remedial Services Request

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					**This 2-sided document is to be completed by the Remedial Service Provider** Remedial Services Information Student Name: Remedial Service (reading, math, writing, other):

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Remedial Teacher Name:______________ Hours/week:

Academic Areas: Please indicate areas of concern and, if known, fill in shaded areas READING level is Experiencing difficulty in: ___Literal Comprehension MATH level is Experiencing difficulty in: ___Mental Computation WRITING level is Experiencing difficulty in: ___Spelling ____Grammar ___On ___Below ___Above ___Letter Recognition ___Phonics ___Word Identification ___Interpretive Comprehension ___Applying skills ___On ___Below ___Above ___Number Recognition ___Counting ___Word Problems ___Applying skills ___Math facts

___On ___Below ___Above ___Legibility ___Spacing ___Organization ___Punctuation/Capitalization ___Applying skills

Any additional testing information Test Name (i.e. Rigby, Terra Nova, ELP, ELA, etc.)

Score

Teaching strategies used to address referral issue:
(i.e., behavior system, time out, modify curriculum, graphic organizers, reward system, small group instruction, mastery learning, cross-age tutoring, technological supports, etc.)

Length of time intervention used

Level of success
1-poor, 3-avg, 5-good

List areas that have not been responsive to treatment:

**This 2-sided document is to be completed by the Remedial Service Provider** In each area, please check all those that apply. General Student Strengths: ___Enthusiastic ___Communicative ___Cooperative ___Logical ___Creative ___Considerate ___Humorous ___Friendly Other information: Work Habits: ___Works independently ___Completes homework ___Has organization skills ___Completes in-class work Other information:

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___Can accept re-direction ___Participates in extra-curricular activities ___Demonstrates desire to learn ___Athletic

___Follows group directions ___Doesn’t turn in homework ___Work often incomplete ___Unorganized

___Works slowly, but accurately ___Works quickly & accurately ___Works quickly, but inaccurately ___Works slowly, but inaccurately

Social/Emotional Development: ___Well behaved ___Lethargic ___Usually follows rules ___Gets out of seat ___Easily frustrated ___Needs routine ___Daydreams ___Inconsistent class behavior Other information: Ability to Work with Group ___ Shows leadership ___ Works well in a group Other information: Reaction to Discipline ___ Accepts responsibility ___Verbal aggression Other information: ___Unable to work alone ___Prefers to work alone

___Impulsive/speaks w/o permission ___Avoids tasks ___Interacts inappropriately w/ peers ___Does not follow class rules

___Unable to work with group

___Resists authority ___ Denies actions ___Physical Aggression

___ Blames others

Amount of Support Needed ___Works independently ___Needs teacher 1:1 Other information: Self Confidence ___Willing to try new things ___Not afraid to make mistakes Other information:

___Needs reminders often ___Needs directions repeated

___Needs much reassurance

___Poor self concept ___Afraid to try new things

___Unable to accept praise ___Sensitive to criticism

Other relevant information: