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Referral for Behavior RTI Services
This form is to formally request assistance from the Behavior RTI team.
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Student Name *
Current Grade *
Name of the person requesting Behavior RTI service
Role of person requesting Behavior RTI services *
Date of referral for BRTI *
MM
/
DD
/
YYYY
List 3 strengths that the student has: *
Student History - Come to the initial meeting prepared to discuss any items checked below. *
Required
Teacher Observations *
Well Below Average
Below Average
Average
Above Average
Well Above Average
Completes class assignments
Completes homework
Follows directions
Follows procedures and rules
Functions independently
Gets along well with others
Motivation and effort
Normal energy level
Organization
Participates in class
Stays on task
Please check MAJOR behavior concerns: *
Required
How long has the behavior(s) been present? *
How often does the behavior(s) occur? *
How severe is the behavior(s)? *
How long does the behavior(s) last? *
Where does the problem occur? (Check all that apply) *
Required
Are there any events or conditions that immediately precede the problem? (Check all that apply) *
Required
Why do you think these problems occur? (Check all that apply) *
Required
How many times has this student been written-up for disciplinary action from administration this school year? *
What interventions or strategies have been tried or are currently in place? *
Date(s) of parent contact(s) regarding problem behavior(s) *
Any other information you feel is important to add. 
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