Post Primary School Form – Class teacher & the learning support/resource teacher(s)


Please fill in all fields marked with an *

* Childs Name:
* Childs Date of Birth:
* Address:
* Parent(s) or Guardian(s) Name:
* Telephone Number(s):
* School:
* Year:
* Course(LC,LCA, PLC etc.):
* Address:
* School Number:
* Name of Principal:
* What is the main reason for this referral?
LearningBehaviourEmotionalOther

* What are the main concerns about this student:

Did the student receive learning support of resource teaching support in primary school? YesNo

If he/she did, please give as much detail as possible (Subjects, number of years, number of classes weekly, duration of classes, size of classes):

Is the student receiving, or has this student received, learning support/ resource teaching hours in post-primary school: YesNo

Learning Support:

Number of years:
In what subject(s):
How often weekly:
Duration of classes:
How many in the group:
Resource teaching support:

Number of years:
In what subject(s):
How often weekly:
Duration of classes:
Please include the results of Standardised (Reading and mathematics) tests done in the last 2 years.

Date:
Name of test:
Results- give S.S. and percentile rank:
Date:
Name of test:
Results- give S.S. and percentile rank:
Date:
Name of test:
Results- give S.S. and percentile rank:
Date:
Name of test:
Results- give S.S. and percentile rank:
Please comment on the following

* Attention:

* Memory:

* Concentration:

* Oral skills:

* Reading- Word attack skills-phonic skills etc.:

* Reading- Comprehension:

* Mathematics- Computational skills:

* Mathematics-Problem solving:

* Spelling:

* Writing skills:

* Fine motor skills:

* Gross motor skills:

* Social skills with teachers/other adults:

* Social skills with his/her peers:

* Behaviour in class:

* Behaviour outside class:

* Is the student receiving any Speech and Language or Occupational Therapy interventionsYesNo:

If so, please give details:

Please give details of any in-school interventions being used with the child, commenting on the efficacy of these interventions etc..:

Any additional information or comments:

Consent

I/We understand that the results of this evaluation will be made known to me/us, to the School Principal, and, where the Principal deems it appropriate, to the relevant members of the school staff.

* Name of Student:
* Principle:
* Learning Support teacher:
* Resource Teacher:
* Date:
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