Raymond High School
Student Intervention Team (SIl) Referral Form
The mission of the SIT Team is to increase the likelihood of positive behavior and academic achievement of students.
The objectives include:
• To work with students at risk for development of chronic behavioral concerns.
• To identify reliable predictors of student behavior.
• To determine the likely function of behavior and recommend function based behavior snpport plans.
• To assist and support teachers, students, and parents in achieving efficient and effective interventions.
Referral Date:
Student:
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Referring Teacher:
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ClasS/Course:
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Grade:
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Reason for Referral (please explain in detail):.
What are your goals/expectations
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for the student?
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What have you tried to change in the environment in which the problem behaviors occur?
Arranged tutoring to improve Student's academic skills
0 Provided extra assistance
Changed seating assignments
0 Changed curriculum
Modified assignments to match student's needs
0 Changed Schedule of activities
o cnher
_
What have you tried to teach the student about expected behaviors?
o Reminders about expected behavior when problem
0 Practiced expected behavior in class
behaviors occur
0 Systematic feedback about behavior
Clarified rules for the whole class
0 Individual school-home contract
Self management program
0 Written agreement with student
o Reinforcement program for expected behaviors
0 Oral contract with student
o cnher
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What responses to the problem behavior have you tried?
Note or phone call
0 Referral to school counselor
Individual meeting with student
0 Home-school communication
Conference with parent
0 Loss of privilege
cnher
_
o
o
o
o
o
o
o
o
o
o
Reprimand
Detention
o
Are you aware of any special or unusual circumstances?
family, etc.)
(i.e.: economic issues, substance abuse, homelessness,
dysfunctional
_
AdditionalComments:
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9/9/08
SIT REFERRAL PROCESS
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Referrals: Any student who is struggling academically, behaviorally and/or
socially and where classroom/faculty interventions have not been successfuL
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Complete referral form with as much detail as possible.
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Forward to Pat Kelvington.
o All referral received by Monday 3rd period will be discussed at that
weeks SIT meeting.
.
o Any referrals received after 3 rd period Monday will be discussed the
following week.
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A referral acknowledgement will be sent out by the SIT team for all referrals
received.