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): * Parent/Guardian Email Address: * School: * Year: * Course(LC,LCA, PLC etc.): * Address: * School Number: * School Email Address: * 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: Please enter the letters below and then click on the send button.