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A.S.S.I.S.T. Team Intervention Support Request Form
Please answer the following questions to help guide intervention planning.

To be eligible for and A.S.S.I.S.T. Team referral, the student must have the following:
* Active involvement from the local IEP team including the SLP and the ED Consultant.
* After submission, intervention requests will be screened to determine whether all local resources have been exhausted before the A.S.S.I.S.T. Team will provide support.
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Staff Contact Name *
Staff Contact email and phone number *
Case Manager's name
Student Name *
School District and Building *
Parent Names *
Child's date of birth *
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Grade and classroom teacher name *
List other team members (SLP, OT, PT, ED, School Psych, etc).
Have the parents been contacted and informed of this request? This is not a requirement, it is just for informational purposes. *
What are your primary concerns? *
Check the following strategies you have attempted: *
Describe specific behavioral concerns with this student (i.e. tantrums, meltdowns, aggression, etc. Include when/time of day you typically see these behaviors. *
Please list specific likes/dislikes your student demonstrates. *
Please list several strengths you see this student possessing. *
List any additional information that you feel may be helpful to the A.S.S.I.S.T Team. *
Please list other concerns you have regarding this student.
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