HiddenDate MM slash DD slash YYYY Referring Teacher Name* First Last Email* Section BreakStudent Name* First Last Grade*Please ChooseToddlerEarly Childhood - LotusEarly Childhood - PeonyEarly Childhood - Plum BlossomGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12Areas of Concern1. Please be as specific as possible. This information will be used in assisting with the evaluation process.2. Check major areas of concern and briefly describe the child’s behavior or performance in each area checked. If you have identified more than one area of concern, circle the area you consider to be the highest priority.* Academic Social/Emotional Gross/Fine Motor Affective (activities of daily living) Health Related Behavior Communication Other (specify below) A. Describe Specific Concerns*B. Describe any alternative strategy used and its outcome*C. How often does the student’s area(s) of concern prevent him/her from being successful in class (i.e. rarely, occasionally, often, every day, etc.). Provide any additional information on the lines provided below.*D. Do you believe the student in question requires a conversation with the Learning Support Specialist, inclusion support, or pull-out support? Explain below.*E. Describe any additional information you believe may help us provide this student with the best learning environment possible.*