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.
Your Name (Last, First)
Student Name (Last, First)
Reason For Referral
What are student's strengths:
What motivates positive behavior for the student?
What is the problem behavior?
Physical Contact/Physical Aggression
Disruption of Learning Environment
Dress Code Violation
Electronic Device Violation
Clearly define the problem behavior. (What do you see and hear student doing?)
When, Where, and with Whom are problem behaviors most likely?
Possible motivation/perceived reason (function of behavior - Check one box only)
Obtain Adult Attention
Obtain Peer Attention
FOR TEACHER ONLY: Please check all of the TIER I interventions attempted ( All interventions must be implemented consistently for 1-2 weeks.)
Restate Expectations/Modeling Behavior
Positive Praise/Positive phone call home
Parent/Teacher Contact (Minimum of 2)
Teacher to Teacher Support
Partner with strong peer
Proximity/Check for Understandings
Student Behavior Form
Give Positive Choices
Differentiation of Task
If "Other", please provide a summary of attempted interventions
Goal (s) I would like to see this student reach is/are:
A copy of your responses will be emailed to the address you provided.
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