CST Referral Note Template
25-26_CST_Tracker_-_ES_Evaluations.xlsx
Print Ready Layout • Sheet Template View
Fit to Page (Portrait)
Active Tracker (ES Evals)
Referral Note-Taking Template
ES CST Bell Curves
ES Ineligible Form
Student Name
Campus / Grade
Date of Referral
CST Partners
1. LANGUAGE DOMINANCE & BILINGUAL CONSIDERATIONS
Primary Home Language
e.g., Spanish, Portuguese, French, Arabic
Language Dominance Assessment
English Bilingual L1 Muted
Translator Requirements
For Parent Comm. For Eval Testing KeyLingo Filed Bilingual Eval Reqd
WIDA Score / English Proficiency Impact Context:
2. REFERRAL REFUSAL / NO TO EVALUATION JUSTIFICATION
Compliance Field
CST Preliminary Decision: Proceed with Proposal Refuse Referral (Say No) Defer for MTSS / Tiered Interventions
Standard Refusal Justifications
Lack of documented tiered academic or behavioral interventions.
Suspected struggles are primarily due to English Language Acquisition.
Existing recent clinical or private diagnostic data rules out educational impact.
Detailed Decision Justification / MTSS Rationale
3. EVALUATION PLANNING & PROPOSAL MATRIX
Planning Matrix
| Evaluation Domain | Proposed | Considered, Not Proposed | Accepted / On File | Domain-Specific Rationale / Exclusion Justification |
|---|
| Cognitive (Psychological) | | | | |
| | | | |
| Educational Assessment (LDTC) | | | | |
|
| Social History (Social Work) | | | |
|
| Speech & Language | | | |
|
| Motor (OT/PT) | | | |
|
| Specialized (FBA/Neuro/Psych) | | | |
|
4. CST DISCUSSION NOTES & ACTION ITEMS
Action-Oriented
CST Partner Tasks / Follow-ups
Notify Parent / Obtain Written Consent to Evaluate Input Planning Decision into Hanes Tracker / EdPlan Bilingual Evaluator Request Sent (if applicable) Email Eligibility Update to School Partners
Referral Discussion Comments / Program Notes Lines for handwriting
Student Details & Language Refusal / Exclusion Rule Evaluation Matrix
Use as standard sheet in CST ES Eval file
