Assessment and/or Intervention Form
Student’s Name: Parent’s Name:
Date of Birth: Grade:
School: Date of Meeting:
(Please note: Parent-School Partnership form is to be reviewed and discussed with a parent as a component of ongoing communication and student success planning.)
Dear Parent/Guardian,
Our school is committed to supporting student success. If a student experiences a specific need in academics or behavior, it is important for school personnel and parents to work together. We want to include you in the planning and monitoring of your student’s targeted interventions.
At this time, our Team may conduct a variety of interventions within the general setting. These focused/target interventions will be delivered in different levels of intensity according to your child’s needs.
A record of your student’s assessment, interventions, and progress will be kept in a file at the school.
The quality and effectiveness of interventions for your child will be strengthened by your involvement.
Therefore, you will be given feedback as to the meaning and results of the assessments and interventions and will receive information/ideas on how to support school success at home.
Specific Area of Concern: ___________________________________
Assessment Tool(s) and Staff Involved:___________________________________
_______________________________________________________________________
Intervention(s) and Staff Involved:________________________________________
Purpose of Assessment or Intervention: _____________________________
I understand that my child will be participating in a targeted assessment/intervention with the appropriate school staff. I understand that I am invited to participate in the planning and monitoring of my student’s school success as relates to these assessments and interventions. I understand that I may request an evaluation for my child.
Parent/Guardian Signature Date
Telephone Email
Staff/School Contact Phone
Revised 8/2015

Multi-Tiered System of Supports (MTSS)
MTSS is a system that provides educational support and interventions to all students at increasing levels of intensity based on their individual needs. The goal is to address concerns and intervene early so that students can be successful. MTSS is a process designed to help schools focus on interventions that are matched to student needs and monitored on a regular basis. The information gained from the MTSS process is used by school personnel and parents to adapt instruction and to make decisions regarding the student’s educational and/or behavioral plan.
Examples of educational and/or behavioral concerns include:

Reading (mechanics, vocabulary, comprehension)

Math (applied math, calculation, facts)
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Written language (spelling, organization, grammar)
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Attention, listening, following directions
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Behavior (following rules, complying with teacher requests, socializing with peers)

Work quality, homework completion
The Collaboration Team:
The Collaboration Team is comprised of parents and school staff who hold specific insights and areas of expertise that can be used to help the student succeed.
Through the inquiry process, the Collaboration Team parents will:

Be informed about interventions planned for your child.

Be notified of the increase or decrease of support (academic and/or behavioral) depending on your child’s needs.

Receive regular progress monitoring reports about how your child responds to the interventions provided.
Level of instruction/intervention :
Revised 8/2015