Behavior Specialist Request Form

Behavior Specialist Request Form

Brownsville Independent School District

Special Services

Service Requested (check one)

Campus Date

Contact person Phone

ARD Teacher Planning Period

Student DOB

Teacher Grade Room #

Disability ARD Date

Required:

1. Parent Conference Date(s)

2. Counselor Referral Date(s)

3. Discipline Referral Date(s)

Attach:

▢ Daily schedule

▢ Office referrals

▢ Functional Behavioral Assessment Interview Forms

▢ Current or Drafted FBA/BIP

Understand that failure to provide the above information may lead to processing delays

Parent signature

(Required for observations only)

Campus Administrator Signature Date

Special Ed. Supervisor Signature Date

Please send completed request and attachments to Special Services

ATTENTION: Yvonne Santa Ana Phone:698-1179

DATE COMPLETED PACKET RECEIVED

Services will be provided in the order received

Note: Completed packets must be submitted to Special Services at least 5 working days prior to the scheduled ARD

Revised Aug. 2006