Executive Edge Referral Form

Tier: Tier 2 Small-Group Support | Grade: 6 | Session Duration: 30 minutes

Instructions: Please complete all sections below with objective data. Collected information will guide targeted interventions for improving the student's executive functioning skills.

I. Student Information

1. Student Name:



2. Date of Referral:



3. Referring Teacher:



4. Homeroom/Subject:

II. Academic Performance Data (Last 4 Weeks)

• Math Grade:
  
  
  
• ELA Grade:
  
  
  
• Science Grade:
  
  
  
• Social Studies Grade:
  
  
  
• Total Missing Assignments:
  
  
  

III. Behavior Frequency Checklist (Past 4 Weeks)

Use the following scale: N = Never, R = Rarely, S = Sometimes, O = Often, A = Always

• Lost or misplaces materials: ____
• Missed deadlines/assignments: ____
• Requires frequent redirection to stay on task: ____
• Difficulty starting tasks independently: ____
• Easily distracted in class: ____
• Struggles with multi-step instructions: ____
• Procrastinates until last minute: ____
• Difficulty transitioning between activities: ____

IV. Executive Function Rating Scales

Rate each skill (1 = Needs significant support, 5 = Consistently demonstrates skill) and provide specific examples.

1. Organization (e.g., keeps materials organized, uses planner): ____
Examples/Evidence:

2. Time Management (e.g., meets deadlines, plans work effectively): ____
Examples/Evidence:

3. Task Initiation (e.g., begins tasks promptly without prompting): ____
Examples/Evidence:

4. Self-Regulation (e.g., manages emotions, handles frustration): ____
Examples/Evidence:

V. Previous Interventions and Outcomes

List any strategies already implemented and their effectiveness.

Strategy 1:






Outcome 1:

Strategy 2:






Outcome 2:

VI. Referral Justification

Summarize why this student would benefit from the Executive Edge Tier 2 group:

VII. Referring Teacher Signature

Name:


Date:


Signature:

Executive Edge Strategy Worksheet

Instructions: For each executive functioning skill area below, brainstorm at least two practical strategies you can try. Be specific about how and when you will use each strategy. Use the space provided to write your ideas and any extra notes.

I. Organization

1. Strategy 1:
   
   
   
   
2. Strategy 2:
   
   
   
   
   Additional Notes:
   
   
   
   
   
   

II. Time Management

1. Strategy 1:
   
   
   
   
2. Strategy 2:
   
   
   
   
   Additional Notes:
   
   
   
   
   
   

III. Self-Regulation

1. Strategy 1:
   
   
   
   
2. Strategy 2:
   
   
   
   
   Additional Notes:
   
   
   
   
   
   

Executive Edge SMART Goal Worksheet

Instructions: Use this worksheet to develop a clear, actionable SMART goal targeting one area of executive functioning. Complete each section below, then write your full goal and action steps at the end.

1. Specific

What exactly do I want to accomplish? (Be precise and concrete.)

2. Measurable

How will I measure my progress? (What data or evidence will show success?)

3. Achievable

Is this goal realistic given my time and resources? Explain why I can reach it.

4. Relevant

How does this goal address my specific executive functioning challenge? Why is it important?

5. Time-Bound

What is my deadline? (Specify a date or time frame.)

6. My SMART Goal

Combine the elements above into one concise statement.

7. Action Steps

List 2–3 concrete steps you will take to start working toward your goal:

1. Step 1:
   
   
2. Step 2:
   
   
3. Step 3:
   
   

8. Progress Tracking

How and when will I check my progress? (Daily, weekly, checklists, planner notes, etc.)

Executive Edge Baseline Self-Assessment Worksheet

Instructions: Rate yourself honestly on each executive functioning skill using the scale below, then reflect on your rating. Use the space provided to write your thoughts.

Rating Scale: 1 = Needs significant support 2 = Developing 3 = Adequate 4 = Skilled 5 = Consistently strong

I. Organization

Rating (1–5): _____


Why did you choose this rating?






What does being well-organized look like for you?

II. Time Management

Rating (1–5): _____


Why did you choose this rating?






What does effective time management look like for you?

III. Self-Regulation

Rating (1–5): _____


Why did you choose this rating?






What does strong self-regulation look like for you?

IV. Focus Area for This Week

Based on your lowest rating above, which skill will you focus on improving?


My focus skill: ___________________________________


Why is this important for me right now?

Use this worksheet as a reference when drafting your first SMART goal in our next session.

Executive Edge Personal Goal Worksheet

Instructions: Use this worksheet to draft a SMART goal targeting your focus skill. Answer each prompt with as much detail as you can, then write your final goal at the end.

I. Focus Skill

What skill will I focus on this week?

II. SMART Goal Components

Specific: What exactly will I do?

Measurable: How will I know I’m successful? (What data or evidence will I collect?)

Achievable: Why is this goal realistic for me? (Consider time and resources.)

Relevant: How does this goal help improve my focus skill?

Time-Bound: When will I complete this goal? (Date or time frame.)

III. My Draft SMART Goal

Combine the elements above into one clear, concise statement:

IV. Peer Feedback

Partner’s suggestion to make this goal stronger:

V. Action Steps

List 1–2 concrete steps you will take first:

1. Step 1:
   
   
   
2. Step 2:
   
   
   

VI. Final SMART Goal

After feedback and revisions, rewrite your final goal here:

Use this worksheet to guide your daily reflections and track your progress in the Weekly Reflection Log.

Executive Edge Week 1 Reflection Log

Instructions: Each day this week, record the executive functioning action you tried, the evidence or data you collected, how you felt about your effort, and one concrete next step for tomorrow. Bring this log to our next session.

Day 1 (Date: ____________)

Action I Tried:

Evidence/Data (e.g., planner entry, checklist):

How I Felt About My Progress:

Next Step for Tomorrow:

Day 2 (Date: ____________)

Action I Tried:

Evidence/Data:

How I Felt About My Progress:

Next Step for Tomorrow:

Day 3 (Date: ____________)

Action I Tried:

Evidence/Data:

How I Felt About My Progress:

Next Step for Tomorrow:

Day 4 (Date: ____________)

Action I Tried:

Evidence/Data:

How I Felt About My Progress:

Next Step for Tomorrow:

Day 5 (Date: ____________)

Action I Tried:

Evidence/Data:

How I Felt About My Progress:

Next Step for Tomorrow:

Executive Edge Organization Practice Worksheet

Instructions: Use this worksheet to apply the binder setup and color-coding strategies modeled in our session. Complete each section thoughtfully, then use your notes to organize your materials this week.

I. Binder Section Setup

List each subject or class you have. For each, write the section name and the materials you will keep there.

1. Subject/Section Name: ____________________________
   
   Materials to Include:
   

   • ________________________________________________
     
   • ________________________________________________
     
   • ________________________________________________
     
     

2. Subject/Section Name: ____________________________
   
   Materials to Include:
   

   • ________________________________________________
     
   • ________________________________________________
     
   • ________________________________________________
     
     

3. Subject/Section Name: ____________________________
   
   Materials to Include:
   

   • ________________________________________________
     
   • ________________________________________________
     
   • ________________________________________________
     
     

(Add more sections on the back if needed.)

II. Color Coding Plan

Assign a color to each subject to keep notes and deadlines organized. Then describe how you will apply that color in your binder and planner.

(Feel free to list additional classes on the back.)

III. Folder Label Design

On the front of each folder or divider, you will create a clear label using your subject color and a brief title. Sketch or write your label design below for two sections.

1. Section Name: ________________________
   
   Label Sketch or Wording:
   
   
   
   
   
   

2. Section Name: ________________________
   
   Label Sketch or Wording:
   
   
   
   
   
   

IV. Implementation Plan & Reflection

1. When will you set up your binder and apply color coding this week? (Be specific: day, time, location.)
   
   
   
   
   
   

2. What challenges might you face when organizing your binder? How will you overcome them?
   
   
   
   
   
   

3. How will you check each day that your binder remains organized? (e.g., quick 1-minute check before class.)
   
   
   
   
   
   

Keep this worksheet on your desk while organizing. Refer back as you work and adjust your plan as needed.

Executive Edge Week 2 Reflection Log

Instructions: Each day this week, record the organization strategy you tried, the evidence or data you collected, any challenges you faced, how you felt about your progress, and one concrete next step for tomorrow. Bring this log to our next session.

Day 1 (Date: ____________)

Organization Action I Tried:




Evidence/Data (e.g., color-coded page, planner entry):




Challenges I Faced:




How I Felt About My Progress:




Next Step for Tomorrow:

Day 2 (Date: ____________)

Organization Action I Tried:




Evidence/Data:




Challenges I Faced:




How I Felt About My Progress:




Next Step for Tomorrow:

Day 3 (Date: ____________)

Organization Action I Tried:




Evidence/Data:




Challenges I Faced:




How I Felt About My Progress:




Next Step for Tomorrow:

Day 4 (Date: ____________)

Organization Action I Tried:




Evidence/Data:




Challenges I Faced:




How I Felt About My Progress:




Next Step for Tomorrow:

Day 5 (Date: ____________)

Organization Action I Tried:




Evidence/Data:




Challenges I Faced:




How I Felt About My Progress:




Next Step for Tomorrow: