STARS REFERRAL FORM
Referring Teacher(s): Grade: ____________________________
Student Name: Referral Date:_______________________
Date of Birth: Parent/Guardian:____________________
Address: Parent/Guardian:____________________
____________________________________ Phone:____________________________
Parent Notification Date/Details: _________________________________________________
- Phone Call
- Written Correspondence (email, note in planner, etc.)
- Conference
Primary Concern:
- Academic Area: _____________________________________
- Behavioral
- Other Specify: ____________________________________
What are the child’s strengths?
_________________________________________________________________________________________________________________________________________________________________________________________________________
What academic/behavioral problems are you seeing?
_________________________________________________________________________________________________________________________________________________________________________________________________________
In what setting/situation does the problem occur most often?
______________________________________________________________________________________________________________________________________
In what setting/situation does the problem occur least often?
______________________________________________________________________________________________________________________________________
What accommodations, modifications and differentiation strategies have you tried?
_________________________________________________________________________________________________________________________________________________________________________________________________________
What, if any, Tier 2 interventions have been tried?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What was the success rate of those interventions?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What is the child’s level of independence in the area of concern?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you have any other pertinent information that the team should know about this student?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________