Form Sts0123 - Gifted Referral
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1St. Lucie Public Schools
Gifted Referral
DEMOGRAPHICS
Student Name
Other ID
DOB
Ethnicity
Gender
Grade/School
Primary Language
Homeroom Teacher
Parent/Guardian Name:
Phone
Address (Street, City, Zip)
Benchmark Scores 3-12 (Most recent)
Student
District
Student
District
Student
District
Reading
Math
Science
FCAT Level or (Most recent)
Student
District
Student
District
Reading
Math
SAT-10 percentile
How does this student demonstrate a need for advanced curriculum? Be specific.
Student is above social maturity of classmates?
Yes No
Student works above regular class curricula? Yes No At times
Date of Parent Conference ____/____/____
Reason for Referral:
In order to obtain further information about your child’s abilities, we need your permission to conduct sensory, cognitive, and academic screenings with
your child. By signing below, I give permission for the educational screening of my child.
Parent and/or Guardian Signature ______________________________________________________________________ Date ____/____/____
HEARING
VISION
1000 Hz
2000 Hz
4000 Hz
FAR
NEAR
Circle One
R
RIG T
20/___
20/___
P
F
L
LEFT
20/___
20/___
P
F
Audiometric screening at 25db
Muscle Balance
Plus lens (+1.75)
Color Perception
Passed: __________________
Failed: _________________
P
F
P
F
P
F
Comments:________________________________________________
Comments:________________________________________________
Person Responsible/Position
Person Responsible/Position
Instrument
Instrument
Used: _______________________________ Date ____/____/____
Used: ________________________________ Date ____/____/____
Further Evaluation Required: Yes No If yes, attach report.
Further Evaluation Required: Yes No If yes, attach report.
ABILITY
ACADEMIC (If needed)
VERBAL
NONVERBAL
COMPOSITE
READING
MATH
WRITING
Standard Score - %ile
Standard Score - %ile
Standard Score - %ile
Standard Score - %ile
Standard Score - %ile
Standard Score - %ile
Instrument Used: _______________________ Date ____/____/____
Instrument Used: _______________________ Date ____/____/____
Person Responsible: ______________________________________
Person Responsible: ______________________________________
Date of Meeting: ____/____/____
Parent Letter sent on: ____/____/____
Meeting Outcome:
Further evaluation not requested at this time.
Further evaluation requested at this time. -
Obtain Consent for Formal Evaluation (or Reevaluation for ESE students), and review Procedural
Safeguards with parent.
Team Members Present:
School Counselor __________________________________________ Parent ____________________________________________________
School Psychologist ________________________________________ Parent ____________________________________________________
Teacher ___________________________________________________ Other _____________________________________________________
Gifted Referral
STS0123 Rev.07/12
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