IKE-E Initial Referral Form
File: IKE-E
INITIAL REFERRAL FORM
Date: ______________________________
Name: _____________________________ Previous Retentions (grade): _________________
Date of Birth: ________________________ Previous Referrals (i.e., speech, medical, PET)
________________________________________
Grade: _____________________________
Teacher's Name: ______________________________________________________________
School: ______________________________________________________________________
Attendance Record: ____________________________________________________________
Referrals to be submitted by February 15
Decision for retention made by June 1
Name of Bath School Attended: __________________________________________________
Reason for concern: ________________________________________________________________________________________________________________________________________________________
Physical Development: ________________________________________________________________________________________________________________________________________________________
Academic Development: Reading ________________________________________________
Math ___________________________________________________
Speech and verbal expression _______________________________
Particular strengths: ________________________________________________________________________________________________________________________________________________________
Particular weaknesses: ________________________________________________________________________________________________________________________________________________________
Parent communications (dates and topics discussed): ________________________________________________________________________________________________________________________________________________________
Teacher's Signature: ___________________________________________________________
Principal's Signature: ___________________________________________________________
Recommendations: ________________________________________________________________________________________________________________________________________________________