Summary Of The Student’s Academic
Achievement And Functional Performance (A)

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  Student's name ,
   
 
  Date of Summary Date of Summary
 
 
Reason for Exit (check the ONE that applies):  
 

Strengths/Interests/Learning Preferences:

Pre-Academic / Academic / Functional Skills (Note results of any general State or district-wide assessments):

Cognitive Abilities:

Communication Skills:

Motor Skills (Fine/Gross):

Health:

Social/Emotional/Behavioral:

Self Help/Adaptive:

Pre-Vocational/Vocational:

 
Agency Linkages (check agencies known to be working with the individual or could be a resource to the individual) Agency Contact Person and phone number, if known
Place each contact on a separate line
(max. 7 lines, one for each service)
California Children's Services (CCS)
Dept. of Social Services (DSS)
County Mental Health (CMH)
Department of Rehabilitation
Probation
Regional Center
Other: 

Other Recommendations: