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REFERRAL FORM FOR PARTICIPATION IN THE HIGHLY CAPABLE SCREENING PROCESS
Name of Person Completing Form
Relationship to Student
Please choose
Parent/Guardian
Teacher
Self
Peer
Other
Student First Name
Student Last Name
Date of Birth
Current Grade
Choose...
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Gender
Male
Female
Gender X or Non-binary
Teacher's Name
Current School
--- Please Choose ---
LP Brown Elementary School
Garfield Elementary School
Lincoln Elementary School
Boston Harbor Elementary School
Centennial Elementary School
McLane Elementary School
Pioneer Elementary School
Madison Elementary School
Roosevelt Elementary School
McKenny Elementary School
Hansen Elementary School
Jefferson Middle School
Thurgood Marshall Middle School
Reeves Middle School
Washington Middle School
Olympia High School
Capital High School
Avanti High School
Olympia Regional Learning Academy
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
Choose...
Washington
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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.