Long Beach School District
TST-2B Behavior Referral for Interventions
Student: ___________________________ Teacher:____________________________ Tier___ Sped___
School: QES RES HMES LBMS LBHS LBAS
Grade: ____
Date Submitted:_________________
Instructions: Only mark items the student exhibits on a consistent, daily basis. You must prioritize and
identify up to two (2) target behaviors only. Additional referrals may need to be completed if multiple
behaviors are targeted for intervention.
STUDENT IS DISRUPTIVE IN CLASS:
___fidgets
___is overly active
___will not remain in seat
___talks out of turn
___disturbs others when they are working
___constantly seeks attention: ____from peers ____from teacher
___overly aggressive with others: Anyone particular?___________________________
___belligerent toward teachers and others in authority
___defiant or stubborn
___impulsive
___can’t wait his/her turn
___acts without thinking of the consequences
STUDENT IS WITHDRAWN/ANXIOUS:
___shy, timid
___has difficulty making friends
___sits alone in cafeteria
___does not join in group activities
___overly conforms to rules
___daydreams/out of touch
___has difficulty expressing feelings
___appears depressed
___rarely smiles
___appears to be tense
___appears frightened or worried
___cries easily
___reports fears or phobias
STUDENT HAS:
___been on runaway status
___been caught stealing at school
___left class without permission
___cursed school personnel
___threatened to harm school personnel
___been suspended for fighting
___attempted suicide
___had tobacco violations at school
___had drug/alcohol violations at school
OTHER SOCIAL/EMOTIONAL BEHAVIORS:
___lacks self-confidence
___says “can’t do” even before attempting
___reacts poorly to disappointment
___overly dependent on students/adults
___pretends to be sick
___has poor grooming or personal hygiene
CLASSROOM INTEREST:
What are the student’s academic strengths/interests?
____________________________________________________
____________________________________________________
When is the student most successful (e.g. behaviorally, socially)?
____________________________________________________
____________________________________________________
MOTIVATION:
___tends to give up easily
___completes only partial assignments
___rarely completes homework
___has difficulty getting started on assignments
STRATEGIES ATTEMPTED: (Attach documentation)
___phone calls
___parent conferences
___student conferences
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PBIS:
___Bearcat/Pride bucks
___Earning of privileges
___Contracts
___Peer support
___PBIS classwide incentive plan (attach)
___Planner/agenda signed
___Retaught expected behavior
___4:1 positive verbal feedback
___Role played/practiced expected behavior
___Pre-correction and redirection
___Other____________________________________________
NEGATIVE CONSEQUENCES:
___Change in classroom seating
___Time out
___Denial of privileges
___Verbal warnings
___Change in student schedule
___Office referral
___In-school suspension
___Out-of-school suspension
OUTCOME OF STRATEGIES:
___Slight improvement in behavior
___Improvement followed by a decline in behavior
___Negative behavior increased
___No change in behavior
What is the primary target behavior that, if replaced with a more positive behavior, the student would be successful in
your class (Behavior 1)?
____________________________________________________________________________________
Answer the above question with the secondary target behavior, if applicable. (Behavior 2)_________________________
__________________________________________________________________________________________________
POSSIBLE FUNCTION: Limit to 1 or 2 functions per behavior. Keep in mind that there may be more than one function
if there is more than one behavior. Please put B1 or B2 beside the function if identifying two target behaviors.
The student GAINS:
___Teacher/adult attention
___Peer attention/acceptance
___Desired items
___Preferred activities/privileges
___Control over others or situations
___Sensory stimulation
The student AVOIDS or ESCAPES:
___Teacher/adult attention
___Peer attention/acceptance
___Non-preferred activity
___Instructional task
___A transition
___Sensory stimulation
The student’s failure to perform the appropriate behavior(s) is primarily due to a:
___Skill Deficit (The student does not know how to perform the appropriate behavior/skill.)
___Performance Deficit (The student is capable of performing the appropriate behavior/skill but chooses not to do so.
Please provide any additional information which would help in choosing the appropriate intervention for the student.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
August, 2015
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