TIERED APPROACH - INTERVENTION WORKSHEET/REFERRAL FORM

Step 1: complete first page over time while applying various interventions (consult Support Team if you like)
NOTE: This worksheet may be used for any student in your class, but it should be completed for students who will be presented at the in-school team
meeting and before the next level of support is pursued.

Student: Grade: Teacher(s): Date observation initiated: ________________

Date submitted to LST: __________________

Area of Difficulty Data Source Intervention Instructional Model Used Staff Support
(Assessment Evidence)

□ □ □ □ Whole class Primary Support

□ □ □ □ Small group
□ Classroom teacher
□ □ □ Individual □ SELC/LST
□ LST
□ □ Other (please describe)
□ Secondary Support

PM/DRA levels; Observations: □ EA

Level: ____Date:_________ □ Volunteer
Level: ____Date:_________ □ Peer Buddy
Level: ____Date:_________ □ Other (please
Level: ____Date:_________ describe)

Other Languages spoken in the home other than English (by parent) ______________________ by student _________________ Stage: _______

Speech/Language Data
□ Expressive Language □ Receptive Language □Literacy Skills
□ speaks in short phrases/grammatical errors □ difficulty following verbal instructions □ difficulty decoding
□ limited vocabulary □ difficulty answering questions □ weak comprehension skills
□ doesn’t participate verbally in class □ Written Language Concerns □ Articulation concerns

Behaviour Data
□ Relating to peers □ Relating to family □ Attendance Problems □ Other (Describe)
□ Relating to adults □ Classroom behaviour □ Emotional/Social

Comments:
Step 2: After the intervention has been applied, complete the section below and bring this form to the in-school/multi-disciplinary meeting.
Please call parents first, inform them you are making the referral, and ask about hearing and vision (record below).
Please attach any relevant examples of student work and/or copies of teacher tracking sheets
How many times was the Was the intervention successful?
intervention applied?

□ Less than 5 □ Yes, the skill has improved □ No, the skill has not improved. Please see below for next steps.
and no further intervention
□ Between 5-10
is required.
□ More than 10 □ Continue the intervention
Show evidence:
□ Other (please specify) □ Modify the intervention by _____________________________________________
□ Try a new intervention (begin a new tracking sheet and attach)
□ School Base Team Referral/Plan of Action: ____________________________________
________________________________________________________________________
□ Other: ______________________________________________________________

Although permission is not required, it is the responsibility of the teacher to inform the parents that a referral is being made to the
school based Student Support Team. This occurred on _____________________________ by ____________________________.
Additional Comments by Parents: ________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Hearing checked? Y/N date/results: _______________________________ Vision checked? Y/N date/results: ________________________________

ACTION PERSON RESPONSIBLE Present at Meeting ___________________________________________

___________________________ ___________________________ Date of Meeting: ______________________________________________

___________________________ ____________________________ Signatures: Teacher (s) _________________________________________

___________________________
___________________________
LST _________________________________________
____________________________
Support _________________________________________
Principal _________________________________________
____________________________

___________________________ _____________________________
Follow-up Date: _______________________________________________
TIERED APPROACH - INTERVENTION WORKSHEET/REFERRAL FORM ______________________________________

NOTE: This worksheet may be used for any student in your class, but it should be completed for students who will be presented at the in-school team
meeting and before the next level of support is pursued.

Student: Grade: Teacher(s): Date :

Area of Difficulty Data Source Intervention Instructional Model Used Staff Support
(Assessment Evidence)

□ □ □ □ Whole class Primary Support

□ □ □ □ Small group
□ Classroom teacher
□ □ □ Individual □ SELC/LST
□ LST
□ □ Other (please describe)
□ Secondary Support

PM/DRA levels; Observations: □ EA

Level: ____Date:_________ □ Volunteer
Level: ____Date:_________ □ Peer Buddy
Level: ____Date:_________ □ Other (please
Level: ____Date:_________ describe)

Duration: _______

After the intervention has been applied, complete the section below and bring this form to the in-school/multi-disciplinary meeting.
How many times was the Was the intervention successful?
intervention applied?

□ Less than 5 □ Yes, the skill has improved □ No, the skill has not improved. Please see below for next steps.
and no further intervention
□ Between 5-10
is required.
□ More than 10 □ Continue the intervention
Show evidence:
□ Other (please specify) □ Modify the intervention by _____________________________________________
□ Try a new intervention (begin a new tracking sheet and attach)
□ School Base Team Referral/Plan of Action: ____________________________________
________________________________________________________________________
□ Other: ________________________________________________________________