JERSEY CITY COMMUNITY CHARTER SCHOOL
128 Danforth Avenue, Jersey City, NJ 07305
Phone: (201) 433 – 2288 - Fax: (201) 433 – 5803
School Website: www.jcccsonline.org
Eugene Brown, Head of School
Bima Baje, School Business Administrator/Board Secretary
____________________________________________________________________________________________________________
Referral for Social/Emotional Behavior Intervention Services Form
Student:
Grade:
Date:
Person Making Referral:
Parent/Guardian:
Date of
Birth:
Parent/Guardian
Informed of Referral:
Method of Informing
Parent:
Phone
Note
Email
Mail
Date:
Number of Days Missed
this School Year:
Yes
Address:
Phone:
No
Dominant Language:
Summarize any communications held with parent/guardian to date:
Summarize any relevant medical or health information for this student:
Student Strengths/ Areas of Concern: Please indicate any strengths or special talents that the student displays:
Social / Emotional / Behavioral Concern Checklist
Please place a checkmark in the
Passively Off-Task (Short
Attention Span)
next to each area of concern for the student within your classroom.
Fighting/Physical
High anxiety levels
Aggression/Contact
Talking out/disruption
Lying
Excessive Activity Level
Theft
Withdrawn Behavior
Low self-confidence
Running Away from Adults
Low frustration tolerance
Work Avoidance
Vandalism
Demanding attention
Disrespectful/Inappropriate
Language
Poor Adult Relationships
Negative Self-Statements
Excessive sadness/
depression
Arguing with peers
Constant Complaining/Whining
Out of Seat
Harassment/bullying/threats
Invading Other’s Physical Space
Teasing Peers
Noncompliance with Requests/
Insubordination
Careless Work Completion
Temper Tantrums
Family change/environmental
concerns
Community difficulties
Hygiene
Review the boxes (social, emotional, behavioral) you checked. Prioritize your top 1-3 concerns (1 = most
important). When prioritizing, try to give preference to skills/concerns that if improved would improve other
skills/concerns. Focus only on those variables that are under the control of school.
1.
2.
3.
What is the expected level of performance that you would like to see from the student?
Are there times in which the problem is more severe or maximized (i.e., certain times of day, certain days of the
week or month, etc.)? If so, when?
Are there environments (settings or situations) in which the problem is more severe or maximized? If so,
where?
Interventions Attempted: Please describe what tier 2 interventions have been implemented and the results of
those interventions. Note that a minimum of two interventions should be tried before referring a student to the
Child Study Team.
Intervention Description
Describe each intervention
that you used to address the
student’s concern(s).
Intervention Delivery
List key details about delivery of the
intervention, such as (1) where & when
the intervention was used; (2) the adultto-student ratio; (3) how frequently the
intervention happened; (4) the length of
time each session of the intervention
lasted; (5) who delivered the
intervention.
Assessment Data
List type of data collected and
when, the student’s baseline,
and the student’s progress
monitoring data
Type of data:
Baseline:
Progress
Monitor:
Type of data:
Baseline:
Progress
Monitor:
Type of data:
Baseline:
Progress
Monitor:
What would be the best day(s) and time(s) for a member of the Child Study Team to observe the student having
the difficulties that you describe above?
To be completed by the Special Education Coordinator:
There is adequate data and information to move on to the intervention and accommodation
planning portion at this time. A Child Study Team meeting will be scheduled for:
There is not enough data to adequately plan interventions or strategies/accommodations at this
time. A planning meeting is scheduled for: