Universal Tier 2 RFA: social, emotional, behavioral, interventions.
Tier 2 RFA for student intervention.  This form is for school sites to utilize as their tier 2 RFA for on site support and intervention.  RFA's at this level require that parents and teachers have already been contacted and told of the social emotional and behavioral concerns and how concerns may be affecting their student and others in the classroom or during unstructured times and how it may be impeding a student's educational experience socially, developmentally and academically. Prior to submitting a tier 2 RFA classroom supports should be enlisted and in place. 

STAFF:
Please complete the following referral form and check all of the concerns that you have for the student. Be sure to have contacted the parent/guardian making them aware of the concerns you will outline in this RFA.  The Wellness Center and Tier 2 team will also contact the parent/guardian, if necessary, to gain consent and determine the best option for intervention i.e.; group or individual, depending on the student needs and the effectiveness of group or individual intervention for the student. Referral for next tier level of support may be necessary if the student concerns are beyond the scope of the tier 2 supports and interventions.

PARENT/GUARDIAN:
Our district is focused on helping students thrive in their academic environment by helping them deal with stressors and decrease the potential for negative social emotional outcomes. This can be accomplished through a variety of activities such as social groups, one on one conversations, mindful practices and social circles.  Before filling out this form please ensure your students teacher is fully aware of your concerns and classroom supports have been in place.  If you feel your student may benefit from any of these interventions please fill out the form completely and submit it to the school site tier 2 team for inquiry.  Someone will be in contact with you once you complete and submit your request for assistance. Completion of this form is not a guarantee your student will be placed on an intervention. Each student and their particular situation will be assessed on a case by case basis for the best possible and available response.

STUDENT SELF-REFERRAL:
Students may self refer to see a counselor regarding any personal concerns, academic challenges, or social emotions questions.  Parents/guardians must be contacted in certain situations which your counselor will explain and parent/guardian signed consent must be attained for any student to be placed into a group or individual intervention. Someone will contact you soon after you submit your request for assistance. 
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Name of person filling out form. First and Last *
First and last name of the student being referred
Relation to the student being referred
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