Instructional Support Team Referral Form
Strategic Intervention
Hornell City School District
Name of Student
Date of Birth
Grade/Teacher
Referred By/Date /

Please list student’s strengths and talents:

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Please check areas of difficulty:

ReadingComprehension / Processing

WritingSpeaking

Math Calculations/SkillsEmotional Coping Skills

School BehaviorsHealth & Fitness

Social Skills/InteractionsAttention Difficulties

AttendanceOther:

Teacher Concerns:

Student’s Current Services / Frequency:

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Indicate accommodations tried in the classroom:

Preferential Seating

Used chunking (allowed student to complete smaller sections of work at a time)

Informally consulted special area people for suggestions and strategies

Talked to child’s previous teachers

Other:

Indicate targeted interventions (Tier 2) that have been tried prior to referral:

Spoke to student about concerns

Changed student instruction to meet student needs

Small group work or 1-to-1 work with adult

Used classroom peer tutor

Designed and implemented behavioral and/or academic modification or reward systems

Provided student help after class or school

Discussed concerns with parent(s) on the telephone

Sent home notices regarding behaviors/school work

Daily log with parents

Conducted a conference with parent(s) in school

Other:

Please complete the attachedintervention documentation with dates

Please Return to Building Level IST Chairperson

Classroom Intervention Planning Sheet

Teacher/Team: Date: Student:

Student Skill Difficulty Definition #1:

Student Skill Difficulty Definition #2:

[Optional] Person(s) assisting with intervention planning process:

Intervention Description / Intervention Delivery / Review Dates / Assessment Data
Describe each intervention that you plan to use to address the student’s skill difficulty. / List key details about delivery of the intervention, such as:; (1) where & when the intervention will be used; (2) the adult-to-student ratio; (3) how frequently the intervention will take place; (4) the length of time each session of the intervention will last;. / Record dates when the data is reviewed to evaluate the intervention. / Note what classroom data will be used to establish baseline, set a goal for improvement, and track the student’s progress during this intervention.
Where:
Frequency:
Adult to Student Ratio:
Session Time: / Type(s) of Data to Be Used:
Baseline (e.g., trial percentage) / Skill Review Data (e.g., trial percentage)
Where:
Frequency:
Adult to Student Ratio:
Session Time: / Type(s) of Data to Be Used:
Baseline (e.g., trial percentage) / Skill Review Data (e.g., trial percentage)
Where:
Frequency:
Adult to Student Ratio:
Session Time: / Type(s) of Data to Be Used:
Baseline (e.g., trial percentage) / Skill Review Data (e.g., trial percentage)