Targeted Team Referral Form
The mission of the Targeted Team is to increase the likelihood of positive behavior and
academic achievement of students.
The objectives include:
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To work with students at risk for development of chronic behavioral concerns.
To identify reliable predictors of students behavior.
To determine likely function of behavior and recommend function based behavior support plans.
To assist and support teachers, students, and parents in achieving efficient and effective interventions.
Student Name:
Grade:
Teacher Name:
Date:
Room#:
What are your behavioral goals and /or expectations for this student?
What are the student’s academic and social strengths?
Situations prompting the problem
behavior
Describe the problem
behavior
Why do these behaviors keep
happening?
What have you tried to change in the environment in which the problem behaviors occur?
* Modified
*Changed seating
__Arranged tutoring to improve
assignments to match
assignments
student’s academic skills
__Other
student’s needs
__Changed schedule
*Provided extra
__ Changed curriculum
of activities
assistance
What have you tried to teach the student about expected behaviors?
* Reminders about expected
*Practiced expected
__ Systematic
behavior when problem behavior
behavior in class
feedback about
occurs
behavior
* Clarified rules for the whole class __ Individual school- __ Self management
home contract
program
__ Reinforcement program for
__Written agreement * Oral contract with
expected behaviors
with student
student
What responses to the problem behavior have you tried?
* Note or phone call
__ Referral to school
__ Individual meeting with
counselor
student
__ Reprimand
__ Time out
__ Detention
* Conference with
__ Loss of privilege
__ Home-school
parent
communication
Additional Comments:
__Other
__Other