General Information

For how many months have you known this pupil?

How well do you know him/ her?

How much time does he/ she spend in your class per week?

What class of yours is he/ she in? (i.e regular 5th grade, 7th grade math, counseling, learning disability etc)

Has he/ she ever been referred for special class placement, services, or tutoring?

What kind and when?

Does this pupil have any illness or disability (either physical or mental)?

Please describe

What concerns you most about this pupil?

Please describe the best things about this pupil (feel free to write any comments about the pupil's work, behavior, or potential)

Academic Performance

Add academic subjects and rate pupil's performance for each subject



How would you rate pupil's performance?

Academic Behavior

Compared to typical pupils of the same age:

How hard is he/ she working?

How appropriately is he/ she behaving?

How much is he/ she learning?

How happy is he/ she?

General Behavior

Acts too young for his/ her age

Drinks alcohol without parents' approval

Argues a lot

Fails to finish things he/ she starts

There are very little or a few things that he/ she enjoys

Bowel movements outside toilet

Bragging, boasting

Trouble concentrating or can't pay attention for a longer time

Trouble getting his/ her mind off certain thoughts; obsessions

Can't sit still, restless or hyperactive

Clings to adults or too dependent

Complains of loneliness

Confused or seems to be in a fog

Cries a lot

Cruel to animals

Cruelty, bullying or mean to others

Daydreams or gets lost in his/ her own thoughts

Deliberately harms self or attempts suicide

Demands a lot of attention

Destroys his/ her or others things on purpose

Doesn't eat well

Defiant to rules at home, school or elsewhere

Doesn't socialize well with other kids

Doesn't feel any guilt after misbehaving

Easily jealous

Fears certain animals, situations or places other than school



Feels worthless

Fells or complains that no one loves him/ her

Accident prone

Gets into many fights

Gets teased a lot

Hangs around people who are a bad influence

Hears sound or voices that aren't there

Impulsive or acts without thinking

Lying or cheating

Nervous movements or twitching

Nightmares or Night terrors


Too fearful or anxious

Feels too guilty


Overtired without good reason


Physical problems without known medical cause

Aches or pains (not stomach or headaches)


Nausea or feels sick

Problems with eyes (not if corrected by glasses)

Rashes or other skin problems


Vomiting or throwing up

Others that were not mentioned


Name behavior

Rate behavior

Name & Signature of Teacher