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2025-2026 Shafter Intervention Form
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* Indicates required question
Email
*
Your email
Your Name
(
Su Nombre
)
*
Your answer
I am a...
(
Yo soy...
)
*
Staff Member (funcionario)
Student/ Parent/Family/Community Member (estudiante/padre/familia/miembro de la comunidad)
Student Name
(nombre del estudiante)
*
Your answer
Student UID (6 Digit Number)
(
número de estudiante)
*
Your answer
Student Grade Level
(
grado del estudiante)
*
Choose
9
10
11
12
Student Has: (check all that apply)
(estudiante tiene un:)
*
504
IEP
Student does not have a 504 or IEP
Required
Check all areas of concern for this student:
(motivo de preocupación):
*
Negative attitude or behaviors impacting student access
Defiance of Authority
Continued Classroom Disruption
Pervasive anger
Fighting/provoking a fight
Harassment of another student(s)
Family Concerns
Lack of positive peer relationships
Significant change in weight, hygiene, and/or appearance
Student demonstrates or vocalizes feelings of panic or anxiety
Recent loss of a loved one
Suspected substance use/abuse
Tardies/Attendnace
Suicidal Thoughts (please call 76014 immediately)
Other:
Required
Has parent contact by phone been made by the teacher? (Reminder: the best Tier I practice is a phone call by the teacher. If translation is needed, please contact the Title I Office)
(¿Ha contactado el profesor con los padres por teléfono?
)
*
Yes
No
N/A
Has counselor contact been made by the teacher?
(¿Ha contactado el profesor con el consejero?)
*
Yes
No
N/A
What interventions have been provided by the requester that have encouraged the student to show Shafter PRIDE? (Please check all that apply. Tier II/III team will review Synergy documentation.)
(¿Qué intervenciones ha proporcionado el solicitante que han animado al alumno a mostrar Shafter PRIDE?)
PRIDE Expectations Reviewed with Student
Tutoring
Previous Tier II Form
PRIDE Recognition (5 Star App/General of the Month/Verbal Praise/Etc.)
Contacted Counselor
Email through Synergy
Message Notification through Canvas
Support Staff Intervention (i.e. Instructional Aid calling home, Social Worker, Interventionist)
None
Other:
Would you like this to be a General Quarters (Student Advocacy and Restoration Center) Referral for the student in addition to them receiving Tier II support?
(¿Desea solicitar el centro de defensa del estudiante?)
*
Yes
No
Briefly describe incident and/or the request for intervention.
(Describa brevemente el incidente y/o la solicitud de intervención.)
*
Your answer
Request for Independent Studies (ISP) placement (
Counselors Only
)?
Yes
No
Clear selection
A copy of your responses will be emailed to the address you provided.
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