Handy referral form for Healthy Start
A referral form for schools
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.
Referring Staff Member
Students Medi-cal #
Primary Language at home
Has the parent been contacted regarding your concerns?
If yes, what was their response? Are they open to SSPT services?
Is student in special education?
Background for referral
Reason you are referring the student
Language Assessment candidate
Disrespectful to adults
Failing 2 or more classes
Fixed mind set
Little to no effort
Little to no work completed
Low scores or academic performance
Poor organizational skills
Does the child demonstrate any of the following
Cries easily and/or often
Difficulties with attention/concentration
Difficulties with learning
Struggles with social skills
Defiance towards authority
Gang affiliation/tagging crew
Check all that apply
Has positive peer social interactions
Has positive adult social interactions
Completes in-class assignments
Participates in groups
Attention seeking behavior
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.
What are the student’s academic and social skills strengths?
2. Academic or Behavior concern
What is impeding the students learning?
3. Classroom Interventions and Strategies Implemented
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
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
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
3. Primary language support provided by
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?
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