PBIS Request for Assistance
Please fill out this form if you feel your HHS student would benefit from any of the following programs:

Check in/ Check Out:
Receive one-on-one attention on a daily basis from a counselor or teacher mentor; Personal goal assessment completed daily by classroom teacher; Counselor or teacher checks on how they are doing; Counselor or teacher will use teachable moments to encourage students; Parent notification of student progress every 2 weeks.

Advisory Council:
Serve on the PBIS Advisory Council for 2 or more months; Meet student mentors and Tier II PBIS Team during Group 3 Activity Period; Discuss various topics such as social media issues, work ethic, social skills, student accountability, being respectful to others, building trust, etc.; Assigned student mentors who work with them (Lunch/Break Buddy); Parent notification of student progress every 2 weeks.

Character Coach:
Student receives one-on-one character coaching (one to two times a week); Coaching consists of specific topics such as impulse control, anger management, anger stop signs, risky thinking, respecting others differences, social skills, academic checks, etc.; Parent notification of student progress every 2 weeks.

Email address *
Today's Date: *
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Student Name *
Your answer
Grade Level *
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Your connection to this student *
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Please select any external behaviors that you have seen the student display repeatedly from the list below: *
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Please select any internal behaviors that you have seen the student express: *
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Comments: Please add any additional information that would help in the placement of this student into the PBIS Tier II program.
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