You must have JavaScript enabled to use this form. 1 Start 2 Preview 3 Complete Page 1 of 3 Student information (Please fill out form for only one student at a time. Complete additional form for each additional.): Student Name & Grade 1. Student Name * 2. Grade * Teacher Information 3. Teacher Name: * 4. Phone Number: * 5. Email: * Academic Information: 6. Content Areas of Need * Grade Band Content Area Standard Selections (select one) 7. Grade Bands: * Primary (grades pk/K/1) Elementary (grades 2/3/4/5) Intermediate (grades 6/7/8) Secondary (grades 9/10/11/12) Content Areas: Language Arts, Math, Science, Social Studies -select all that appl Primary Primary - Language Arts Describe characters, settings, and major events in a story Demonstrate ability to separate sounds within words (for example, “dog” = “/d/-/o/-/g/” sounds) Demonstrate ability to blend separated sounds into words (for example, “/d/-/o/-/g/” = “dog”) Isolate and pronounce blends and digraphs within words (for example, /sk/, /cl/, /sh/, /th/) Letter-sound correspondences (phonemic awareness and phonics) Know and apply grade-level phonics and word analysis skills in decoding unknown words Read common high-frequency words by sight Determine the meaning of words and phrases as they are used in a text Produce clear and coherent writing (e.g. numbers and letters) Demonstrate command of the conventions of standard English grammar and usage when writing or speaking Primary - Math Count to tell the number of objects Solve simple addition and subtraction problems Compare measurable attributes (size, color, etc) Identify and describe shapes Work with time, money, measurement (age appropriate) Primary - Science Daily and seasonal changes, sun, energy, weather Properties of objects and everyday materials Physical and behavioral traits of living things Motion and materials Basic needs of living things Primary - Social Studies Time Money Resources Models/maps Diverse cultural practices Elementary Elementary - Language Arts Letter-sound correspondences (phonemic awareness and phonics) Know and apply grade-level phonics and word analysis skills in decoding unknown words Read common high-frequency words by sight Read with sufficient accuracy and fluency to support comprehension Determine the meaning of words and phrases as they are used in a text Refer to details, pictures, and examples in a text when explaining what the text says explicitly and when drawing inferences from the text Determine the meaning of general academic and domain-specific words and phrases in a text Interpret information presented visually, orally, or quantitatively (e.g., in charts, graphs, diagrams, time lines, animations, or interactive elements on Web pages) Produce clear and coherent writing in which the development, organization, and style are appropriate to task, purpose, and audience (grade appropriate) Demonstrate command of the conventions of standard English grammar and usage when writing or speaking Elementary - Math Simple addition and subtraction Multidigit addition and subtraction Solve simple problems involving money, measurement, and time Simple multiplication and division Solve simple word problems Elementary - Science Atmosphere Changes in motion Interactions within habitats Earth’s resources, surface, and living history Matter and forms of energy Behavior, growth, and changes Electricity, heat, light, and sound Solar system Ecosystems, rocks, minerals, and soil Cellular to multicellular Elementary - Social Studies Biographies and timelines Physical/political maps Systems of government Cultural diversity Globes/geographic tools/longitude/latitude Intermediate Intermediate - Language Arts Write arguments to support claims with clear reasons and relevant evidence Cite specific textual evidence to support analysis of primary and secondary sources Demonstrate understanding of figurative language, word relationships, and nuances in word meanings Read with sufficient accuracy and fluency to support comprehension Determine the meaning of words and phrases as they are used in a text Determine the meaning of general academic and domain-specific words and phrases in a text Interpret information presented visually, orally, or quantitatively (e.g., in charts, graphs, diagrams, time lines, animations, or interactive elements on Web pages) Read and comprehend informational texts, including history/social studies, science, and technical texts Produce clear and coherent writing in which the development, organization, and style are appropriate to task, purpose, and audience (grade appropriate) Demonstrate command of the conventions of standard English grammar and usage when writing or speaking Intermediate - Math Simple arithmetic Multidigit arithmatic Represent and interpret data graphically Solve problems involving money, measurement, and estimation of intervals of time, liquid volumes, and masses of objects Solve two-step word problems using the four operations Fraction equivalence, rate, ratio, common multiples Solving problems involving area, surface area, and volume Convert like measurement units and decimals Basic geometry (e.g. identify lines and angles) Pre-algebra/algebra (solving problems where letters stand for numbers) Intermediate - Science Earth and space science Life science Physical science Intermediate - Social Studies Early civilizations (India, Egypt, China and Mesopotamia) Empires in Africa (Ghana, Mali and Songhay) and Asia (Byzantine, Ottoman, Mughal and China) Greece and Roman empires Major world religions Monarchies, theocracies, dictatorships or democracies The renaissance and reformation Markets, supply and demand, basic banking Cultural biases U.S. Constitution Industrial revolution Secondary Secondary - Language Arts Cite strong and thorough textual evidence to support analysis of what the text says explicitly as well as inferences drawn from the text Determine the meaning of words and phrases as they are used in the text, including figurative and connotative meanings Integrate and evaluate multiple sources of information presented in different media or formats (e.g., visually, quantitatively) as well as in words in order to address a question or solve a problem Translate quantitative or technical information expressed in words in a text into visual form (e.g., a table or chart) and translate information expressed visually or mathematically (e.g., in an equation) into words Read and comprehend informational texts, including history/social studies, science, and technical texts Produce clear and coherent writing in which the development, organization, and style are appropriate to task, purpose, and audience (grade appropriate Demonstrate command of the conventions of standard English grammar and usage when writing or speaking Use appropriate resources to find information/solutions (e.g., driving maps, google, email/phone directories) Complete applications related to secondary and post-secondary needs (e.g. job, college, housing, financial applications) Life skills (e.g. driving, budgeting, shopping, health and safety needs, intra/interpersonal relationships) Secondary - Math Basic arithmatic/calculations Solve problems involving money, measurement, and estimation of intervals of time, liquid volumes, and masses of objects Measurement Fractions/ratios Work with radicals and integer exponents Pythagorean Theorem Perform operations with numbers expressed in scientific notation Statistics and probability Geometry Precalculus/calculus Secondary - Science Environmental science/geology Biology Chemistry Physics Secondary - Social Studies American history American government Modern world history Economics and financial literacy Contemporary world social issues World geography Social/Emotional/Behavioral Areas of Need 8. Social/Emotional/Behavioral Areas of Need * Needs Domain Indicator (select all that apply): 9. Social: * Peer relationships Conflict resolution Bullying Social isolation Not applicable 10. Emotional: * Self-regulation Empathy Anxiety Depression Not applicable 11. Behavioral: * Off-task, task persistence Noncompliance Verbal/physical aggression Avoidance/escape Not applicable 12. Provide Examples of Needs in more Detail * Leave this field blank
