Parent/Guardian Counseling Referral Form

RTI2-B

Purpose: This referral form is to request brief one-on-one counseling sessions from the school counselor or to request a referral for Centerstone or another private counselor. For assistance with this form, contact Mr. Feck, school counselor.

You might fill out this form if…

  1. Your child has on-going problematic behaviors (e.g., aggression, disruption, excessive shyness, anxiety, etc.).
  2. You have tried 2-3 strategies (e.g., discussions) and the problem behavior has not been affected.

Student:______Grade:______

Teacher:______

***Please fill out the back of this form & turn in to the front office***

*If you have questions about strategies or consequences, please contact Mr. Feck, school counselor, at or at 931-685-1425.

What is/are the main behavioral issues that are a concern to you from your child?

(e.g., Sam has seemed very sad for the past few weeks since his father/mother and I got a divorce.)

What,inyouropinion,would you see your child doing differently that would be better (i.e., goal)?

(e.g., Sam will feel happier than he currently is.)

What would be evidence of a solid first step toward meeting thisgoal?

(e.g., Sam will start smiling more. / Sam will talk with us as a family more.)

Indicate times when some parts of the goal have already beenachieved.

(e.g., Sam usually seems happier when he and I are spending time together.)

______

By signing this form, I am stating that I have custody of this child and can assist in behavioral goals. I understand that this form may mean that the RTI2-B team will review my child’s academic and behavioral data to determine appropriate behavioral supports in the school setting (based on resources available).

______

Name of Parent/Guardian

______

Signature of Parent/GuardianDate

Behavior Management Form

RTI2-B

Tell us some things your child is great at or that you’re proud of as a parent/guardian.

Select below strategies you have tried to help decrease the behavioral issue(s)*:

Ignore minor misbehavior
Praise positive behavior
Define rules
Calm down time (not time out)
Model positive behavior
Discussions / Behavior chart with reward
Play time with child
Apology/Self-reflection
Counseling
Other
______

Select below consequences you have tried to help decrease the behavioral issue(s):

Reprimands
Removal of privileges
Owed time
Time outs
Chores / Contact teacher: How many times? ______
Meeting with teacher: How many times? ______
Other
______
______

Typically, a child’s behavior is “goal oriented.” Select below 1-2 goals your child may have for behaving the way he or she is.

Obtain peer/friend/sibling attention
Obtain adult attention
Obtain items/activities
Avoid peers/adults
Avoid work/tasks / Don’t know
Other
______
______

*If you have questions about strategies or consequences, please contact Mr. Feck, school counselor, at or at 931-685-1425.