The Ewing Public Schools

School

Intervention and Referral Services

Request for Assistance Form

Student Name: Grade: D.O.B.

Date of Request: Referring Teacher:

Parent/Guardian’s Name:

Phone Numbers: (H)(W)(C)

Parent Contact Date:Type/Method of Contact:

Yes No Date

Has parent/guardian(s) been informed about I&RS referral?
Is student new to the district?
Has student been previously referred to I&RS?
Has student been previously referred to CST?
Does student have a 504 plan?
Has the student been retained?
Are you aware of any medical issues and/or medication?* / N/A

(*If student is on medication, have the school nurse indicate type and dosage on the appropriate form.)

Reason for Request for Assistance (Identify Primary Concern):

Student’s Areas of Strength:

District Assessment Data:

Kindergarten / 1st Grade / 2nd Grade / 3rd Grade / 4th Grade / 5th Grade
Aimsweb (K-1 only)
Renaissance Early Lit (K-1 only)
Reading (DRA II)
ELA (Writing) OEQ Writing Sample
STAR Reading Scale Score
Math (Previous EOY)
Math (Current Quarterly)
Other:
6th Grade / 7th Grade / 8th Grade / 9th Grade / 10th Grade / 11th Grade / 12th Grade
ELA (Writing) OEQ Writing Sample
STAR Reading Scale Score (G6-8)
Math (Previous EOY)
Math (Current Quarterly)
Math (Previous Final)
Math (Current Mid-Term)
Other:

Please have the following items available for the Student Success I&RS meeting:

- Copies of report cards and/or progress reports

- List of parent contacts (include dates and summaries of discussions)

State Assessment:

Test / Language Arts / Math
NJ ASK 3 / PARCC / / / /
NJ ASK 4 / PARCC / / / /
NJ ASK 5 / PARCC / / / /
NJ ASK 6 / PARCC / / / /
NJ ASK 7 / PARCC / / / /
NJ ASK 8 / PARCC / / / /
EOC Algebra I (Grades 8-12) / / / /
EOC Algebra II / / / /
EOC Geometry / / / /
Math Connections / / / /
EOC Biology / / / /
English I / / / /
English II / / / /
English III / / / /
Other: / / / /

Please check off any interventions you have tried under the corresponding areas with the following information [NT – Not tried;

S – Successful; and U – Unsuccessful]:

Academic Interventions / NT / S / U / Dates/Duration/Comments
Reduced assignments
Recorded daily assignments
Check and sign agenda
Allowed more time for task
Positive reinforcement
Task broken down
Used different learning approach (aud/vis/kin)
Small group instruction
Individual instruction
Homework buddy
Other:
Behavior Management/Reinforcement/Intervention
Individual conference with student
Time out in room/recess
Using learned strategies of con res/RC
Student writes/calls parent/guardian
Behavior plan/contract (with examples)
Office referrals (with dates & incidents)
Other:
Learning Environment
Changed seat
Changed group
Reduced distractions
Other:
Intervention Programs
In school homework assistance
Peer buddy/Staff mentor (circle one)
Supplemental Reading
Supplemental Math
Tutoring
OT/PT (circle one)
School counselor individual/family (circle one)
Outside counselor individual/family (circle one)
ESL
Speech language/artic (circle one)
Other:

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