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

  • Subject
  • 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

  • Self-conscious

  • Perfectionist

  • 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

  • Constipated

  • Too fearful or anxious

  • Feels too guilty

  • Overeating

  • Overtired without good reason

  • Overweight

  • Physical problems without known medical cause

  • Aches or pains (not stomach or headaches)

  • headaches

  • Nausea or feels sick

  • Problems with eyes (not if corrected by glasses)

  • Rashes or other skin problems

  • Stomachaches

  • Vomiting or throwing up

  • Others that were not mentioned

  • Behavior
  • Name behavior

  • Rate behavior

Completion

  • Name & Signature of Teacher

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