Request for Assistance:

Student: / Grade: /

Teacher:

/ Date:
Type of Concern: ð Academic ð Behavior ð Social-Emotional

1. What’s the Problem? (Check all that apply.)

ð Academic performance ð Work completion ð Noncompliance ð Upset/Crying Inapp. language Disruptive/Talk-out ð Fighting/Aggression ð Withdrawn

ð Other ______

2. Please fill out the student’s schedule:

Time / Subject/Activity / Teacher /
What problem?
/

How Likely?

Low High
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
Transitions / 1 2 3 4

Intervention Referral Form

Please complete this form and place in ______’s mailbox

Student: ______Date: ______

Referring Staff: ______Grade: ______

Behaviors of Concern:

____ Noncompliance ____ Inappropriate Language ____ Stealing

____ Disruptive ____ Physical Fighting ____ Disrespectful

____ Talking out ____ Off-task ____ Work Completion

____ Out of seat ____ Teasing Peers ____ Other______

Please list out daily activities and rate how likely problem behavior will occur in each activity.

Activity / Likelihood of Problem Behavior / Specific Problem Behavior
Low High
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6

Are there safety concerns? If yes, please describe.

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Intervention Request for Assistance Form

Date: ______Teacher/Team:______

Student Name: ______Grade ______

IEP: YES NO 504: YES NO

1.  Check the area(s) of concern:

Problem Behavior / Academic Problems / What is your primary concern?
  Aggressive
  Non-compliant
  Disruptive
  Withdrawn
  Tardy
  Lack of social skills
  Other: /   Reading
  Math
  Spelling
  Writing
  Study Skills
  Organization

2.  Check the strategies that you have tried so far:

General Review / Modify environment or teaching / Teach expected behaviors / Consequences tried
  Review cumulative file
  Talk with parents
  Talk with previous teacher
  Seek peer help
  Classroom assessment
  Other: /   Change seating environment
  Provide quiet space
  Encourage work breaks
  Change schedule of activities
  Modify assignments
  Arrange tutoring to improve student’s academic skills
  Other: /   Give reminders about expected behavior when problem behavior is likely
  Self-management program
  Clarify rules and expected behavior for whole class
  Practice expected behaviors in class
  Contract with student
  Other: /   Increase rewards for expected behavior
  Phone call to parents
  Office referral
  Time-out
  Reprimand
  Lunch detention
  Loss of privileges
  Meeting with parents
  Other:

Request for Assistance

Date: Teacher/Team:

Student’s Name: Grade: IEP: Yes No 504: Yes No

Please identify the student’s strengths (academic interests, social skills, hobbies, sports, etc. )

1. ______

2. ______

Problem Behaviors: (please circle those are areas of concern)

Verbally Harasses Others Disrupts Class Activities

Noncompliant Difficulty completing work

Withdrawn Tardy

Inattentive Other ______

Academic Concerns:

Math Reading Writing Study Skills/Organization All academic areas

Why do you believe this student is engaging in problem behavior? (please circle primary function)

Adult Attention Peer Attention Escape from difficult work/tasks Escape from adult/peer attention

Gain access to preferred activity/item

Comments:

High School, Request for Assistance

Student ______Date ______

Grade ______SLC ______Counselor______

Referral submitted by: ______

1. Student strengths: ______

2. Is the student qualified for Special Education Services? Y N

3. How many days has the student been suspended this year? ______

4. Please give an estimate of student’s academic progress in your classroom:

______(class work)

______(homework)

______(test average)

Problem Behavior(s): Identify Top 3 Most Problematic Behaviors

___ Tardy / ___ Fight/physical aggression / ___ Disruptive / ___ Theft
___ Unresponsive / ___ Inappropriate language / ___ Insubordination / ___ Vandalism
___ Withdrawn / ___ Verbal harassment / ___ Incomplete work / ___ Other
______
___ Verbally inappropriate / ___ Self-injury

What have you tried ? ______

How has it worked? ______

Why do you think the behavior(s) keep happening? ______

Referring teacher, do not write below this line, for Behavior Support team documentation only.

Relevant information has been reviewed: BY: ______

(SST, PBS, counselor, etc.)

 grades  attendance  testing information

 Disciplinary records  other: ______

Recommended for:

 Academic Seminar  HS-BEP  Read Right  Math Support

 Special Ed. evaluation  HS-BEP card only  Other ______

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