Check In Check Out Referral Form
Please complete the following form in order to refer a student to Check In/Check Out. Once the form has been reviewed, you will be contacted about whether or not the student will begin the CICO program.
Email address *
Student's Name *
Your answer
Grade *
Teacher's Name *
Your answer
What behaviors is the student displaying? *
Your answer
What do you believe is the function of these behaviors? *
How many minor referrals does the student have? *
Your answer
How many major referrals does the student have? *
Your answer
Have you contacted the parent about the problem? *
Do you have knowledge of a problem at school or home that could be a possible antecedent to the behaviors? If so, please explain:
Your answer
What are the student's likes? *
Your answer
What are the student's dislikes? *
Your answer
Have the classroom Matrix rules/expectations been revisited? *
Have you documented the following of the classroom-managed minor problem flowchart? *
What interventions have been attempted inside the classroom to reduce the behaviors? *
Your answer
Has Ms. Taria been called to intervene? *
Additional Information/Comments: *
Your answer
A copy of your responses will be emailed to the address you provided.
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