Churchill High School
Student Support Team Teacher Referral
Form (SST)
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Student:
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Grade:
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Name of
Teacher Making Referral:
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Date:
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Please check the social
issues you want the team to
address:
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| Social Behaviors/Difficulties: |
Health/Basic Needs
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Academic Skills
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Isolated
Aggressive/Harrassing
Clasroom Disruption
Withdrawal
Non-Compliance
Talks Out
Victim of Teasing/Harrassing
Family Issues Impact Performance
Recent Loss/Trauma
Attention Issues
Other
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Attendance
Depression
Personal Hygiene
Inadequate Clothing
Inadequate Nutrition
Hearing
Vision
Fine Motor Skills
Gross Motor Skills
IEP
Other
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Reading
Math
Writing
Motivation
Work Completion
Difficulty Following Directions
English Language Issues
Speech
Physical Difficulty
IEP
Other
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Prior Interventions Attempted:
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Cumulative file reviewed for prior educational progress
If possible, input has been requested from
previous year's teachers.
Concerns discussed with parents
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Please describe the problem as
you see it:
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