Referral For Initial Multidisciplinary Team Evaluation (50 Day Timeline) Page 4
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8Asks for help when needed
Enjoys being in class
Inconsistent performance
Other Comments related to student's Work Habits: (consistency with work, test performance, etc).
_______________________________________________________________________________________
_______________________________________________________________________________________
Social Skills / Behavior
Has this student been suspended o No o Yes (how many days) _________________________________
Reasons for suspension _________________________________________________________________
Does this student have a behavior plan? o No o Yes (provide copy)
Have there been any recent changes to the student’s behavior/academics o No o Yes o N/A
_______________________________________________________________________________________
Describe the positive characteristics and strengths of this student. Be specific.
_______________________________________________________________________________________
Describe the student’s classroom behavior:
_______________________________________________________________________________________
Describe how the student interacts with peers and adults:
_______________________________________________________________________________________
Describe the student’s social skills:
_______________________________________________________________________________________
Describe the student’s ability to communicate in the classroom:
_______________________________________________________________________________________
Describe the consequences used to modify behavior (e.g. sent to office, buddy room, detention, behavior chart,
behavior contract, token economy etc.):
_______________________________________________________________________________________
Within a typical week, how many times have you used the above consequences?
_______________________________________________________________________________________
Please indicate the actual observed behavior of the student by checking the boxes below.
KEY: N/O= Not Observed S= Sometimes O= Often
N/O
S
O
Comments
Generally cooperative
Displays mood swings
Referral for Multidisciplinary Team Evaluation
Page 4 of 8
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