SST SUMMARY FORM

STUDENT: ______Lorena Lopez__________ SCHOOL: _____ Clearwater ______ TEAM: ___ SST3 ____ DATE OF INITIAL SST: __ March 31, 1997 ___

PRIMARY LANGUAGE: ___ English ___________ GRADE: __ 7 ___ BIRTHDATE: ___ 1/25/85______ PARENTS: ___ Navidad & Jorge Lopez ___________

STRENGTHS KNOWN CONCERNS QUESTIONS STRATEGIES ACTIONS

Information Modifications Prioritize Brainstorm (Prioritize) Who When
1-Counseling at
Great dancer Family- + one-to-one tutor 2 Does she have a Counseling at Mom and By 4/15
church student
Lives with mom and for English hearing problem? church
Break dancer Not staying on task
13-yr-old brother + met with mom talking 1-Time-out place in
POP
- seat change class
School- 1 An auditory Counseling will
Likes science - suspended 3 By 4/30
3 elementary processing contact home Counselor
times Verbal conflicts 2-summer school
Good attendance schools problem?
with some peers
- Saturday school
Supportive family and some staff Does she need 2-homework center Teacher By 4/12
+ Uncle helping Teacher will set up
Grades- glasses
Likes to read with math
Soc. Studies-D 2- Daily planner Student will
sports Student By 4/12
English-F 3 purchase and use
Risk taker Math-D Academics falling
Enjoys helping PE-C behind, especially 2-re-check vision Mom will set up By 4/12
Mom
young children English and hearing appointment
Health-
Glasses in 4th Comprehension
Works hard 2-quiet place to
grade. Ear aches as weak Mom and aunt will
work with aunt at Mom By 4/30
a child help set up
home
Normal birth
Physical 3 years
ago
2-librarycard Example of an
Dad

Exemplary
SST Summary
Follow Up Date: _________ May 15, 1997 ___________ Invite: ___________both mom and dad and aunt___________________________________________
Team Members Signature & Position: Form
1. Parent _____ Navidad Lopez_________________ 5. _______ Guilda Lowenstein ______________ / ______ Teacher _______________________

2. Student ________ Lorena Lopez ______________ 6. ________ Mel Jurisch__ ________________ / _______ ORC __________________________

3. Administrator _______ Michelle Allen__________ 7. _______ Belinda Guterrez _______________ / ______________________________________

4. Referring Teacher ______ Barney Scnorr _______ 8. ________ Nurse__ _____________________ / ______________________________________

FNCS SST Notes sample.docx