Intervention Team Referral Form

Referring Teacher: __________________________________________________________ Date:

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Student of Concern: ________________________________________________________ GLE:
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Area(s) of Concern:
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Referring to: (circle one)
OT, PT)

Counseling Title 1

Assessments (Please complete all that apply)

Most Recent
Score
On Track
K-3 ODE Reading
Diagnostic
(Full
Measure/Screener
)
K-3 ODE Writing
Diagnostic
(Full
Measure/Screener
)
K-3 ODE Math
Diagnostic
(Full
Measure/Screener
)
OAA- Fall (3rd
Grade only)
Score and
Category
OAA- Spring (3rd
Grade only)
Score and
Category
Report Card Grades
T1
R:
T2
R:
T3
R:

W:
W:
W:

Special Education (Speech,

Comments

M:
M:
M:

R= Reading, W=Writing, M=Math

Trimester
T1
T2
T3

GRL

Fluency Score

Primarily at this point, you are doing Tier I Universal Interventions in the classroom. It is
only after these interventions have been put into place and you see little progress that
we will meet as an Intervention Team and discuss what Tier II interventions should be put
in place.

What interventions have you already done?

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How long have Tier I interventions been in place? (Should be no less than 4 weeks)
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Describe or attach the progress monitoring/data from these interventions.

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Referral for RTI Behavioral Supports

***Behaviors must be impacting academics***
Student:
GLE:
Referring Teacher:

DOB:
Date Interventions Initiated:
Date Referral Submitted:

Students Strengths
1.
2.
3.

Major Concerns
1.
2.
3.

Student History
Has attendance been a
problem?
Past Retention?
Past Evaluations?

NO

YES

If Yes, answer the following

Absences: _____
Tardies:
_______
What grade(s)?
When?

Behavioral Concern: (What does the problem look like?)

How long has the

behavior been
present?
Less than 1
month
1-2 months
3-6 months
More than 6
months

Frequency?
(How often)

Duration?
(How long)

Hourly

Few seconds

Daily
Weekly
Monthly

Few minutes
15-30 minutes
More than 30
minutes

Intensity?
(How severe)
Low
Medium
High
Very high

Where does the problem occur? (Check all that apply)

Classroom

Playground

Spanish Class

Hallway

Math Class

Library

Cafeteria

IG Visits

Other:

Bathroom

Music Class

Other:

Field Trips

Physical Education

Other:

Please describe:
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Are there any events or conditions that immediately precede the problem?
(Check all that apply)
Demand or request to student
Preferred activity interrupted/ended
Non-preferred/difficult task
Denied access to a preferred activity
Non-preferred activity
Touch/physical contact with the
student
Non-preferred social interaction
Loud or disruptive environment
Transitional Times
Provoking comments from students
Attention is given to others
Consequences/Reprimand imposed
Unstructured time
Loss of privilege
Changes in schedule or routine
Other
Please describe: (Ex: Who is the adult giving attention? What activity are they
avoiding?)
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Why do you think these problems occur? (Check all that apply)
Peer attention
Avoid adults
Adult attention
Escape a situation/setting
Obtain items/activities
Gain control over a situation
Avoid tasks/activities
Unknown motivation
Avoid peers
Other:
Please describe:
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What strategies have been tried or are currently in place? (Check all that
apply)
Behavior plan
Shorts breaks
Self-monitoring plan
Set routines/schedules
Change in seating assignment
Notification of upcoming
transitions
Seat by teacher
Other:
Quiet work space
Other:
Change in line order placement
Other:
Please describe:
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Yes
Have you personally taught the school-wide expectations to

No

this student?
Has this student ever been rewarded for displaying these
expectations?

Please attach data from interventions.