NILD Referral"*" indicates required fields Campus*Please make a selectionLakeside CampusPlant Street CampusGrade Level*Please make a selectionPreschool / K51st – 6th GradesDate of referral*Time of referral*Student Name* First Last Teacher Name* First Last Grade Level*Please make a selection1st Grade2nd Grade3rd Grade4th Grade5th Grade6th GradeHandedness* Right Handed Left HandedReading Difficulties* Blending letters or syllables Decoding words; mispronounces multisyllabic words Maintaining fluent reading rate (reads word-by-word, repeats often) Reading small words or ends of words Observing punctuation while reading orally Keeping place while reading Comprehending what is read Making use of context or picture clues Following written directionsSelect all that applyWriting Difficulties* Forming letters Maintaining consistent letter size or slant Gripping pencil correctly Writing at an appropriate speed (too fast/too slow) Spacing letters or words Remember to dot i’s, cross t’s, punctuate sentences, etc. Writing on the line Observing marginal guidelines Copying from the board or book Expressing ideas on paperSelect all that applySpelling Difficulties* Reverses letters (e.g., b/d; p/q) Transposes letters within words (e.g., spot/stop; was/saw) Omits or adds syllables (e.g. official/offal; configuration/configation) Spells phonetically (e.g., says/sez, nature/nacher) Has trouble finding errors Does well on spelling tests but poorly in other writing situationsSelect all that applyLanguage/Thinking Difficulties* Defining words and/or using appropriate vocabulary Explaining a procedure or relating information clearly and logically Understanding directions Memorizing (e.g., Bible verses) Grasping the main idea Anticipating the consequences of his actions (i.e., cause and effect)Select all that applyMath Difficulties* Reverses numerals and symbols (e.g., 5/ ; >/<) Reverses numbers (e.g., 56/65; 1492/1942) Uses fingers to compute Skips problems unintentionally on worksheet or test Doesn’t remember basic math facts Has trouble with alignment and spacing of numbers Has difficulty with place value concepts Has trouble understanding story problemsSelect all that applyGross Motor Difficulties* Running Skipping Hopping (Both Feet) Hopping (One Foot) Throwing Catching OtherSelect all that applyOther Gross Motor Difficulties*Fine Motor Difficulties* Maintaining Correct Pencil Grip Cutting Tying Shoelaces Tracing On Lines Forming Letter/Numbers OtherSelect all that applyOther Fine Motor Difficulties*Body Image Difficulties* Naming Body Parts Drawing A Person OtherSelect all that applyOther Body Image Difficulties*Numbers Difficulties* Counting Objects 1 – 10 Counting To 10 Recognizing Numbers 1 – 10 Writing Numbers 1 – 10 OtherSelect all that applyOther Numbers Difficulties*Concepts Difficulties* Direction Terms: Left/Right Direction Terms: Up/Down Direction Terms: In/Out Direction Terms: Over/Under Direction Terms: Backward/Forward Analogies Making Comparisons (Same/Different/Etc.) Categorizing Naming Days Of The Week Naming Colors Phonological/Phonemic Awareness OtherSelect all that applyOther Concepts Difficulties*Behavior/Social Skills: Appears to be…* Inattentive and Easily Distracted Impulsive/Uninhibited Unable To Work Independently Over-Reacting or Responding Inappropriately In Social Settings Disturbed By Schedule Changes or Interruptions In Routine Inconsistent In Performance (i.e. One Day Is Capable, Next Day Is Not) Easily Frustrated Forgetful (Has trouble getting materials to/from school, remembering homework, etc.) Unorganized Lethargic/Needing Constant Prodding Fearful/Hesitant To Attempt Anything New A Loaner/Withdrawn Clumsy/Poorly Coordinated (Difficulty with skipping, balancing, handling scissors, etc.) Inconsistent In Use Of Preferred Hand OtherSelect all that applyOther Behavior/Social Skills: Appears to be…*Other Observations*What Are The Student's Greatest Strengths?*What Teaching Strategies/Methods Have You Tried That Have Been Effective With The Student?*What Is Your Primary Reason For Referal?*CAPTCHA