Important reminder: An SSPT referral does NOT substitute for reporting suspicion of child abuse/neglect. Mandated reporters are still required by law to report suspicions of child abuse immediately, following LAUSD procedures for reporting.
Referral date:
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Month
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Day
Year
Date Picker Icon
Referring Staff Member
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Student Name
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First Name
Last Name
Grade
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Student address
Parent/Guardian Name
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Phone number
Students Medi-cal #
Primary Language at home
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Has the parent been contacted regarding your concerns?
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Yes
No
If yes, what was their response? Are they open to SSPT services?
Is student in special education?
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Yes
No
Background for referral
Reason you are referring the student
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Language Assessment candidate
Disruptive
Disrespectful to adults
Failing 2 or more classes
Fixed mind set
Health concerns
Hygiene concerns
Language
Little to no effort
Little to no work completed
Low scores or academic performance
Poor attendance
Processing concerns
Poor organizational skills
Social/Emotional issues
Other
Does the child demonstrate any of the following
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Appears sad.depressed
Withdrawn/Isolates self
Eating problems
Sleeping problems
Cries easily and/or often
Suicidal thoughts
Self-harm
Difficulties with attention/concentration
Disorganization/time-management
Difficulties with learning
Hyperactivity
Low self-esteem
Anxious/nervous
Struggles with social skills
Angers easily
Aggressive behavior
Bullying (Target/Aggressor)
Defiance towards authority
Drugs/alcohol
Gang affiliation/tagging crew
Sexualized behavior
Probation
Hallucinations/Delusions
None
Other
Classroom conduct
Check all that apply
Has positive peer social interactions
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No
Yes
Has positive adult social interactions
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No
Yes
Completes in-class assignments
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No
Yes
Completes homework
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No
Yes
Participates in groups
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No
Yes
Attention seeking behavior
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No
Yes
Lacks motivation
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No
Yes
Folows rules
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No
Yes
Initial Description of Concern
Please describe the student’s strengths, your specific academic or behavior concerns and the interventions and strategies implemented to address these concerns.
1. Strengths
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What are the student’s academic and social skills strengths?
2. Academic or Behavior concern
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What is impeding the students learning?
3. Classroom Interventions and Strategies Implemented
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What interventions have you attempted in addressing the area of concern? Include contact with guardians and work with them on the issue. If related to behavior, refer to Behavior Instruction and Intervention Tier 1 Supports Inventory.
4. Intervention Frequency and Duration
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When did the intervention begin? How long was it implemented? How often was it provided? Example: Intervention began October 1st, it was implemented for four weeks and it was provided once a week for 30 minutes
5. Intervention outcomes
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How did the student respond? What progress was observed?
6. Additional relevant information
Where the behavior occurs, relevant social/emotional information, academic history, health concerns, etc
EL or RFEP referral
Only complete if you are referring for the Language Appraisal Team, otherwise scroll to bottom and click on the submit button to complete your referral
1. Language concerns
Identify difficulties and/or areas in which student is not making adequate progress towards English proficiency
2. Date of current language classification
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Month
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Day
Year
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3. Primary language support provided by
Teacher
TA
Other
4. Are there CA or ELD standards not being met?
Identify subject areas and bucket areas of concern
5. What specifically do you want the EL/RFEP student to learn or be able to do?
Submit
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