Referral for Behavior RTI Services
This form is to formally request assistance from the Behavior RTI team.
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Student Name *
Current Grade *
Name of the person requesting Behavior RTI service
Role of person requesting Behavior RTI services *
Date of referral for BRTI *
MM
/
DD
/
YYYY
List 3 of the student's strengths (academic, personal, behavioral, etc): *
Student History - Come to the initial meeting prepared to discuss any items checked below. *
Required
Teacher Observations *
Well Below Average
Below Average
Average
Above Average
Well Above Average
Completes class assignments
Completes homework
Follows directions
Follows procedures and rules
Functions independently
Maintains appropriate voice level in the classroom
Organization
Participates in class
Stays on task
Please check behavioral concerns: *
Required
How long has the behavior(s) been present? *
How often does the behavior(s) occur? *
How severe is the behavior(s)? *
How long does the behavior(s) last? *
Where does the problem occur? (Check all that apply) *
Required
Are there any events or conditions that immediately precede the problem? (Check all that apply) *
Required
Why do you think these problems occur? (Check all that apply) *
Required
How many times has this student been written-up for disciplinary action from administration this school year? *
What interventions or strategies have been tried or are currently in place? *
Outcome of parent contact(s) regarding problem behavior(s) *
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