Request For Supportive Services
Please complete all sections of this form. All responses are confidential, and are only reviewed by our Behavior Intervention Team (BIT). All requests will be reviewed within 1 to 2 days. A response to your request should be received within 3-5 days. If this is an emergency, please contact administration in addition to filling out request.
Email address *
Your Name (Last, First) *
Your answer
Referring Person *
Student Name (Last, First) *
Your answer
Grade *
Required
Reason For Referral *
What are student's strengths: *
Your answer
What motivates positive behavior for the student? *
Your answer
What is the problem behavior? *
Required
Clearly define the problem behavior. (What do you see and hear student doing?) *
Your answer
When, Where, and with Whom are problem behaviors most likely? *
Your answer
Possible motivation/perceived reason (function of behavior - Check one box only) *
FOR TEACHER ONLY: Please check all of the TIER I interventions attempted ( All interventions must be implemented consistently for 1-2 weeks.)
If "Other", please provide a summary of attempted interventions
Your answer
Goal (s) I would like to see this student reach is/are: *
Your answer
A copy of your responses will be emailed to the address you provided.
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