Endeavour Intermediate

Child Study Team (CST)

Request for Assistance

Student Name :            Age : Grade : DOB :      M F

Requesting Teacher :        Parent Contact Made By :         

Date(s) of Parent Contact :        (parent contact must be made for CST form to be processed)      

Date Submitted:        Date Received:        Initial CST Date:        Follow up CST:     

Health (to be given to the nurse to fill out) :

Date:      Vision: Right Eye      P F   Hearing: Right Ear        P F

        Left Eye      P F     Left Ear        P F

        Both ____________ P F     

Record search for health concerns:

Exclusionary Factors (check if an area of concern):

   Readiness to Learn:                         

Retention:                           

Attendance:                           

English Language Learner:                       

Specific Strengths:

Known Data/Present Levels of Performance (e.g., QRI, WASL, ITBS, CBM , STAR , PRPT, Ed Performance)

Areas of Concern:

Reading  Cognitive     Study Skills            Handwriting              Medical

Math        Speech          Behavior                  Fine Motor              Vision

Written Language            Oral Language      Social/Personal      Gross Motor     Hearing

Specific Age/Grade Skills Not Yet Attained (see attached academic skills continuum) :

Interventions (e.g., LAP, ESL , Counseling, Modified Assignments, Behavior Plan, Adult Assistance) :

Who:     What:       When:       Data-Based Growth:

e.g., Jane Doe       Letter Sounds       9/27 - 11/12       12 sounds on 9/27; 16 sounds on 11/12