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REFERRAL FORM FOR PARTICIPATION IN THE HIGHLY CAPABLE SCREENING PROCESS

Name of Person Completing Form

Relationship to Student

Student First Name

Student Last Name

Date of Birth

Current Grade

Gender

Male Female Gender X or Non-binary

Teacher's Name

Current School

Guardian First Name

Guardian Last Name

Guardian Email

Home Phone

No punctuation e.g. 1234567890

Day Phone

No punctuation e.g. 1234567890

Guardian Address

City

State

Zip Code

Comments

Learning Characteristics	Rarely	Sometimes	Often	Most of the Time
Has unusually advanced vocabulary for age or grade level; uses terms in a meaningful way; has verbal behavior characterized by richness of expression, elaboration, and fluency.
Possesses a large storehouse of information about a variety of topics (beyond the usual interests of youngsters his/her age).
Has quick mastery and recall of factual information.
Has rapid insight into cause-effect relationships; tries to discover the how and why of things; asks many provocative questions (as distinct from informational or factual questions); wants to know what makes things (or people) “tick”.
Has a ready grasp of underlying principles and can quickly make valid generalizations about events, people, or things; looks for similarities and differences in events, people or things.
Is a keen and alert observer; usually “sees more” or “gets more” out of the story, film, etc., than others.
Reads a great deal on his/her own; usually prefers adult level books; does not avoid difficult material; may show a preference for biographies, autobiographies, encyclopedias, and atlases.
Tries to understand complicated material by separating it into its respective parts; reasons things out for himself/herself; sees logical and common sense answers.
Motivational Characteristics	Rarely	Sometimes	Often	Most of the Time
Becomes absorbed and truly involved in certain topics or problems; is persistent in seeking task completion. (It is sometimes difficult to get him/her to move on to another topic.)
Is easily bored with routine tasks.
Does not need external motivation to follow through in work that initially excites him/her.
Strives toward perfection; is self critical; is not easily satisfied with his/her own speed or products.
Prefers to work independently and requires little direction from teachers.
Is interested in many “adult” topics, such as religion, politics, sex, race, more than usual for age level.
Often is self assertive (sometimes even aggressive); stubborn in his/her beliefs.
Likes to organize and bring structure to things, people, or situations.
Is quite concerned with right and wrong, good and bad; often evaluates and passes judgment on events, people, or things.

I request and give permission for my child to be evaluated for highly capable services.

REFERRAL FORM FOR PARTICIPATION IN THE HIGHLY CAPABLE SCREENING PROCESS

Learning Characteristics

Motivational Characteristics