Resource Manual for Intervention and Referral Services (I & RS)

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APPENDIX E

SAMPLE FORMS

The forms, inventories and correspondence contained in Appendix E are only samples of

documents used by I&RS teams, and are not the “approved” or “required” forms,

inventories and correspondence. I&RS teams should carefully review the content and

format of the documents to determine their applicability to their schools. Teams are

encouraged to select only the types of documents that apply to their team’s operations,

and adapt the forms for school use, as appropriate. In all cases, forms used by I&RS

teams should be “user friendly,” that is they should be easy for staff to understand and

complete, while providing the team with the maximum possible amount of data and other

objective information on the identified academic, behavior or health difficulties.

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SAMPLE INITIAL REQUEST FOR ASSISTANCE FORM

Confidential

TO: Intervention and Referral Services Team

FROM: ____________________________________________________________

DATE: ____________________________________________________________

STUDENT: ____________________________________________________________

Reasons for Request for Assistance (Must be for school-based issues, i.e., academics,

behavior, school health):

________________________________________________________________________

Specific and Descriptive Observed Behaviors (Hearsay or subjective comments will not

be accepted):

________________________________________________________________________

Please list all teachers and/or specialists who have contact with this student.

________________________________________________________________________

The “Prior Interventions” checklist, on the reverse side of this form, must also be

completed for your request to be considered.

Place the completed forms in a sealed envelope

and deliver to the I&RS team mailbox.

By submitting this form, I understand that I will be a full partner with the I&RS team

for the resolution of the identified concerns.

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SAMPLE INITIAL REQUEST FOR ASSISTANCE

PRIOR INTERVENTIONS CHECKLIST

Confidential

Staff Requesting Assistance: _______________________ Date: ____________

Student: ____________________________________ Grade: ____________

Please indicate the types of interventions you have tried prior to this request for

assistance.

1. Spoke to student privately after class.

a) Explained class rules and expectations. ____________

b) Explained my concerns. ____________

2. Gave student help after class/school. ____________

3. Changed student’s seat. ____________

4. Spoke with parent on the telephone. Phone number __________ ____________

5. Gave student special work at his/her level. ____________

6. Checked cumulative folder. ____________

7. Held conference with parent in school. ____________

8. Sent home notices regarding behavior/school work. ____________

9. Arranged an independent study program for student. ____________

10. Gave student extra attention. ____________

11. Set up contingency management program with student. ____________

12. Assigned student detention. ____________

13. Referred student to guidance _______, substance awareness coordinator _______,

administration _______, other (specify) _________________________________.

14. Other (Please explain.) _______________________________________________

__________________________________________________________________

Staff Member’s Signature: ___________________________________ Date: _______

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SAMPLE CASE COORDINATOR CHECKLIST

Confidential

Date: __________________ Grade/Team/Section: __________________

Student Name: __________________ Date of Birth: __________________

Parent Name: __________________ Parents’ Home Phone:__________________

Address: __________________ Parents’ Work Phone: __________________

City/State/Zip: __________________ Case Coordinator: __________________

DATE SENT DATE RECEIVED DOCUMENT

__________ __________ Initial Request for Assistance, and

__________ __________ Prior Interventions Checklist

__________ __________ Request for Assistance Feedback

__________ __________ Staff Information Collection

(list subject areas)

__________ __________ ________________________

__________ __________ Information Summary Form

__________ __________ Information Collection Reminder

(to whom)

__________ __________ Staff Thank You Memo

__________ __________ Guidance Counselor Form

__________ __________ Discipline Form

__________ __________ Student Advisor Form

__________ __________ School Nurse/Health Form

__________ __________ Parent Letter

__________ __________ Parent Questionnaire

__________ __________ Parent Interview Form

__________ __________ Student Self-Assessment Sheet

__________ __________ Release of Information Form

__________ __________ Cumulative Folder Information:

__________ __________ Current Report Card

__________ __________ 2 Years Prior Report Cards

__________ __________ Standardized Test Data

__________ __________ Attendance Information

__________ __________ Aftercare Parent Letter

__________ __________ Treatment Facility Letter

__________ __________ Other ________________________

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Sample Case Coordinator Checklist page 2 of 2

DATE ACTION TAKEN

__________ Followed-up with staff making the request (e.g., interview,

observation

)

__________ Summarized and quantified teacher information responses

__________ Reviewed referral with counselor

__________ Reviewed referral with substance awareness coordinator

__________ Reviewed referral with I&RS Team

__________ Reviewed alternatives and options

__________ Contacted/met with student

__________ Contacted/met with parent

__________ Obtained consent to release information

__________ I&RS Action Plan Initial Meeting

__________ I&RS Action Plan Follow-up Meeting

__________ Completed I&RS Action Plan Form

__________ Filed I&RS Action Plan Form

__________ Contacted/met with community agency/resource ______________

_____________________________________________________

__________ Other ________________________________________________

Summary of Action (

Use the reverse side of the form, as necessary.):

________________________________________________________________________

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SAMPLE FEEDBACK MEMO

FOR STAFF REQUEST FOR ASSISTANCE

Confidential

TO: ___________________________________________________

FROM: ___________________________________________________

DATE: ___________________________________________________

The status of your request for assistance of the Intervention and Referral

Services Team for _______________________________ is explained

below:

The following indicates the status of the named student with the Intervention

and Referral Services (I&RS) Team:

_____ The assigned case coordinator from the I&RS Team will

contact you to further review the matter.

_____ The in-school assessment process has begun, including

input from other staff.

_____ A home contract has been made. The I&RS Team is

working with the student.

_____ Our preliminary assessment indicates no need for further

action at this time.

_____ Other:

______________________________________________

We will make every attempt to keep you involved and informed within the

laws governing confidentiality.

Thank you for your cooperation and concern.

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SAMPLE

ELEMENTARY TEACHER INFORMATION COLLECTION FORM

Confidential

Student Name: _______________________ Date: ______________________________

Date of Birth: _______________________ Teacher Name: __________________

Grade Level: _______________________ Reason for Request for Assistance: ______

Days Absent to Date: _________________ ____________________________________

____________________________________

Directions: Please provide the information requested in the appropriate spaces below.

Please also attach a copy of the student’s current report card.

Current

Academic

Performance

Levels/Grades

Student

Strengths

Student Areas

for Improvement

Reading/Language Arts

Math

Language Arts

Social Studies

Science

Expressive Arts

Other:

___________________

_____________

________________

Directions: Please place a check before each behavior or action listed below that you have

observed. Remember, only behaviors or actions you have observed should be

noted.

Classroom Performance

 Failure in one or more subject areas  Short attention span, easily

(identify) __________________ distracted

 Drop in grades, lower achievement  Poor short-term memory,

e.g., can’t remember one day to the next

 Needs directions given individually

 Does not ask for help when needed  Finds it hard to study

 Prefers to work alone  Gives up easily

 Does not complete homework  Lacks desire to do well in school

 Does not complete in-class assignments  Has demonstrated ability, but does not

 Homework is disorganized or incomplete apply self

 Other ___________________________

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Sample Elementary Teacher Information Collection Form page 2 of 3

Social Skills

 Tends to stay to self, withdrawn  Disrespects or defies authority

 Lack of peer relationships  Regularly seeks to be center of attention

 Appears lonely  Frequent ridicule from classmates

 Slow in making friends  Appears unhappy/sad

 Disturbs other students  Lacks control in unstructured situations

 Negative leader  Change in friends

 Unyielding or stubborn on positions  Sexual behavior in public

 Argues with teacher  Difficulty in relating to others

 Hits and/or pushes other students  Talks freely about drugs/alcohol

 Threatens other students  Other social behavior of concern:

 Teases other students ________________________________

 Angered by constructive criticism ________________________________

 Demonstrates lack of self-confidence ________________________________

Disruptive Behavior

 Defiance, violation of rules  Obscene language, gestures

 Blaming, denying, not accepting  Noisy, boisterous at inappropriate times

responsibility  Crying for no apparent reason

 Fighting  Highly active, agitated

 Cheating  Erratic behavior

 Sudden outbursts of anger, verbally  Mood swings

abusive to others  General changes in behavior patterns

 Lack of impulse control

If you have checked any item under the Social Skills or Disruptive Behavior sections, please

attach another piece of paper and provide a detailed explanation.

Physical Symptoms

 Underweight  Frequent physical injuries

 Overweight  Deteriorating hygiene

 Smells of tobacco, alcohol marijuana  Dramatic change in style of clothes

 Wears clothes that challenge  Sleeping in class

the dress code or are inappropriate  Glassy, bloodshot eyes

 Appears tense, on edge  Frequent requests to see nurse

 Slurred or impaired speech  Unsteady on feet

 Appears sleepy, lethargic  Problems with muscle or hand-eye

 Impaired vision coordination

 Impaired hearing

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Sample Elementary Teacher Information Collection Form page 3 of 3

Background Information (If known, please do not ask child or family.)

 Attendance problems  Lives with someone other than parent

 Latchkey child  Known medical problem

 Involvement with community agencies  Takes medication

 Death in the immediate family  Previously involved with counseling

 Chronic illness in immediate family  Currently involved with counseling

 Divorce or separation  Previously identified for assistance

 Unemployment  Discusses concerns regarding

 Single parent household drug/alcohol use in the home

 Previously identified  Family member incarcerated or

for drug/alcohol use adjudicated

 Adjudicated for a juvenile offense

Related Services or Programs

a) School-based: b) Community-based:

 Title I  List, if known

 Reading Specialist  ________________________________

 Speech and Language Correctionist  ________________________________

 Gifted and Talented Program  ________________________________

 Substance Awareness Coordinator  ________________________________

 Guidance Counselor  ________________________________

 School Social Worker

 Child Study Team

 Other Specialists or Services

______________________________

Positive Qualities

List 1-3 (or more) skills or other positive characteristics and strengths, both personal (e.g., talents,

traits, interests, hobbies) and environmental supports (e.g., friends, family members, faith

community) that you have observed or that apply for this student:

Skills _________________________________________________________________________

______________________________________________________________________________

Positive Characteristics and Strengths _______________________________________________

______________________________________________________________________________

Environmental Supports __________________________________________________________

______________________________________________________________________________

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SAMPLE

SECONDARY TEACHER INFORMATION COLLECTION FORM

Confidential

Please return this form, in a sealed envelope, to the I&RS Team mailbox by __________.

(date)

TO: I&RS Team

FROM: ______________________________________________________

DATE: ______________________________________________________

REFERENCE: ______________________________________________________

Classes in which the above-named student is enrolled: ____________________________

________________________________________________________________________

Period(s) of the day you see the student: _______________________________________

Check each of the following items that are of concern to you or that you have noticed

regarding the above-named student.

Class Attendance:

______Frequent requests to leave class to see: _____ Frequent tardiness

_____ advisor _____ Frequent absences

_____ nurse _____ Class cuts

_____ other _____________________

Academic Performance:

_____ Drop in grades, lower achievement _____ Present grade (approximately)

_____ Failure to complete in-class assignments _____ Decrease in class participation

_____ Failure to complete homework assignments _____ Short attention span, easily

_____ Cheating distracted

Disruptive Behavior:

_____ Attention-getting behavior, _____ Violating rules

extreme negatives _____ Blaming, denying

_____ Fighting and/or sudden outbursts of anger _____ Obscene language, gestures

and/or verbal abuse toward others _____ Hyperactivity, nervousness

Physical Symptoms:

_____ Sleeping in class _____ Unsteady on feet

_____ Unexplained, frequent physical injuries _____ Slurred speech

_____ Deteriorating personal appearance _____ Frequent cold-like symptoms

_____ Frequent complaints of nausea or vomiting _____ Glassy, bloodshot eyes

_____ Smelling of alcohol or marijuana

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Sample Secondary Teacher Information Collection Form page 2 of 2

Atypical Behavior:

_____ Change in friends, change in behavior _____ Erratic behavior

_____ Sudden popularity _____ Constant adult contact

_____ Older or significantly younger social group _____ Disoriented

_____ Sexual behavior in public _____ Unrealistic goals

_____ Talks freely about substance abuse _____ Depression

_____ Withdrawn, difficulty in relating to others _____ Defensive

_____ Inappropriate responses _____ Unexplained crying

Home/Social/Family Problems:

_____ Family problems _____ Runaway

_____ Peer problems _____ Job problems

_____ Family alcohol/drug problems

Policy/Discipline Code Violations:

_____ Involvement in thefts and assaults _____ Vandalism

_____ Possession of drugs/alcohol _____ Carrying a weapon

_____ Possession of drug paraphernalia _____ Selling Drugs

(e.g., roach clips, bongs, rolling paper)

Extra Curricular Activities

_____ Missed athletic practice without _____ Missed club/group meeting

substantial/acceptable reason without substantial/

_____ Loss of eligibility acceptable reason

_____ Dropped out of activity (name of activity): _______________________________

Please feel free to offer comments (positive or corrective) that you think will be helpful

in addressing this student’s needs. Remember, only comments that are school-based,

school-focused and specific, descriptive, objective/factual and observable are acceptable.

Skills _________________________________________________________________________

______________________________________________________________________________

Positive Characteristics, Strengths, Interests __________________________________________

______________________________________________________________________________

Environmental Supports __________________________________________________________

______________________________________________________________________________

Thank you for your cooperation, caring and concern!

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SAMPLE INFORMATION SUMMARY FORM

Confidential

Student: ______________________________________________ Date: ____________

Case Coordinator: ______________________________________

STUDENT’S ROSTER:

CLASSROOM PERFORMANCE

Failure in one or more subject areas

Drop in grades, lower achievement

Needs directions given individually

Does not ask for help when needed

Prefers to work alone

Does not complete homework

Does not complete in-class assignments

Homework is disorganized or incomplete

Short attention span, easily distracted

Poor short-term memory, e.g., can’t

remember one day to the next

Finds it hard to study

Gives up easily

Lacks desire to do well in school

Has demonstrated ability, but does not apply

self

SOCIAL SKILLS

Tends to stay to self, withdrawn

Lack of peer relationships

Appears lonely

Slow in making friends

Disturbs other students

Negative leader

Unyielding or stubborn on positions

Argues with teacher

Hits and/or pushes other students

Threatens other students

Teases other students

Angered by constructive criticism

Demonstrates lack of self-confidence

Disrespects or defies authority

Regularly seeks to be center of attention

330

STUDENT’S ROSTER:

Frequent ridicule from classmates

Appears unhappy/sad

Lacks control in unstructured situations

Change in friends

Sexual behavior in public

Difficulty in relating to others

Talks freely about drugs/alcohol

Other social behavior of concern

DISRUPTIVE BEHAVIOR

Defiance, violation of rules

Blaming, denying, not accepting responsibility

Fighting

Cheating

Sudden outbursts of anger, verbally abusive

to others

Lack of impulse control

Obscene language, gestures

Noisy, boisterous at inappropriate times

Crying for no apparent reason

Highly active, agitated

Erratic behavior

General changes in behavior patterns

PHYSICAL SYMPTOMS

Underweight

Overweight

Smells of tobacco, alcohol marijuana

Wears clothes that challenge the dress code or

are inappropriate

Appears tense, on edge

Slurred or impaired speech

Appears sleepy, lethargic

Impaired vision

Impaired hearing

Frequent physical injuries

Deteriorating hygiene

Dramatic change in style of clothes

Sleeping in class

Glassy, bloodshot eyes

Dramatic change in style of clothes

Unsteady on feet

Problems with muscle or hand-eye

coordination

331

STUDENT’S ROSTER:

BACKGROUND INFORMATION

Attendance problems

Latchkey child

Involvement with community agencies

Death in the immediate family

Chronic illness in immediate family

Divorce or separation

Unemployment

Divorce or separation

Previously identified for drug/alcohol use

Adjudicated for a juvenile offense

Lives with someone other than parent

Known medical problem

Takes medication

Previously involved with counseling

Currently involved with counseling

Previously identified for assistance

Discusses concerns regarding drug/alcohol use

in the home

Family member incarcerated or adjudicated

RELATED SCHOOL-BASED SERVICES

OR PROGRAMS

Title I

Reading Specialist

Speech and Language Correctionist

Substance Awareness Coordinator

Guidance Counselor

School Social Worker

Child Study Team

Other specialists or services:

_____________________________________

Related Community-based Services and Programs:

________________________________________________________________________

332

Positive Characteristics, both personal (e.g., skills, talents, traits, interests, hobbies) and

environmental (e.g., friends, family members, faith community):

PERSONAL

Skills ____________________________________________________________

_________________________________________________________________

Talents _________________________________________________________________

_________________________________________________________________

Traits _________________________________________________________________

_________________________________________________________________

Interests _________________________________________________________________

_________________________________________________________________

Hobbies/ _________________________________________________________________

Activities

_________________________________________________________________

Other _________________________________________________________________

ENVIRONMENTAL

Friends _________________________________________________________________

Family _________________________________________________________________

Faith

Community _________________________________________________________________

Other _________________________________________________________________

Use the spaces below to make comments and observations based upon the summary review

of data. Comments must be school-based, school-focused

and be specific, descriptive,

objective/factual and observable.

________________________________________________________________________

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INTERVENTION AND REFERRAL SERVICES

SAMPLE INFORMATION COLLECTION REMINDER MEMO

Confidential

TO: ____________________________________________________________

FROM: ___________________________________________________________,

I&RS Team Member

DATE: ____________________________________________________________

SUBJECT: ____________________________________________________________

A few days ago, the I&RS Team sent you the I&RS program’s information collection

form on the above-named student. It is essential that we have an accurate and complete

profile of this student to develop an appropriate intervention and referral services action

plan. We would appreciate your cooperation in returning the form now.

Please see _______________________________________________ if this is a problem.

Attached is another form in the event that the one previously supplied to you is not

available. If you need an additional form or have questions or concerns, immediately

contact the I&RS Team member identified above.

Thank you for your cooperation.

Attachment

c:

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INTERVENTION AND REFERRAL SERVICES

SAMPLE STAFF THANK YOU MEMO

Confidential

TO: _________________________________________

FROM: _________________________________________, I&RS Team Member

DATE: _________________________________________

SUBJECT: Thank You for Reporting Information on __________________________

(student’s name)

Thank you for your cooperation in returning the information collection form for the

above-named student. Your input will be added to information gathered on the student

from a variety of sources. A determination on remedial action will be made soon.

Respecting the laws governing confidentiality, we will make every attempt to keep you

informed.

The cooperation and support of the entire school community is vitally important for the

success of the I&RS Team in helping staff, parents and students in need of assistance.

Thank you for your cooperation.

c:

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SAMPLE SCHOOL COUNSELOR FORM

Confidential

TO: _________________________________________________________________

FROM: (Case Coordinator Name), I&RS Team

DATE: _________________________________________________________________

REFERENCE: _________________________________________________________________

GRADE: ___________________

The I&RS Team is gathering information on the above-named student. Your input is essential in

developing a complete and accurate profile of this student. If there is information you prefer not

to commit to writing or if you have any questions, please immediately contact me or another

member of the team.

Confidential Information:

 Yes  No Has a psychological evaluation been conducted on this student?

If yes, please describe: _________________________________

 Yes  No In addition to your role, are you aware of any kind of counseling

or therapy (current or past) that has been provided to the student?

If yes, please describe: _________________________________

 Yes  No Has any type of educational testing been conducted on this

student? If yes, please describe: __________________________

____________________________________________________

Parent Contacts:

Please provide information on the number, purposes and outcomes of parent contacts regarding

this student.

______________________________________________________________________________

Guidance Information:

Please give any additional information that you think would be helpful in the team’s assessment

of the student, including skills, positive characteristics and environmental supports. (Use the back

of the form if necessary.)

______________________________________________________________________________

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SAMPLE ATTENDANCE FORM

Confidential

TO: ___________________________________________________________

FROM: Intervention and Referral Services Team

REFERENCE: ___________________________________________________________

DATE: ___________________________________________________________

Please provide attendance data on the student named above for the time period of

_____________ _____, _________ to _____________ _____, _________.

The attendance information either may be supplied on this form or in the standard format

used by your office. Whichever format is used, please be sure to provide actual dates of

absences; indicate whether the absences were excused or unexcused; and where possible,

please cite explanations given for absences.

DATE

OF

ABSENCE

EXCUSED UNEXCUSED EXPLANATION FOR ABSENCE

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SAMPLE DISCIPLINE FORM

Confidential

TO: __________________________________________________________

FROM: Intervention and Referral Services Team

REFERENCE: __________________________________________________________

DATE: __________________________________________________________

Please provide the information requested below for the above-named student and return the

form to the I&RS Team by _________________________________________________

The number of referrals to date: ______________________________

The number of times parents have

been contacted regarding the student’s behavior: ______________________________

The number of days for each detention that has been assigned to the student and the reason(s) for

each:

_______ ____________________________________________________________

The number of days for each suspension that has been assigned to the student and the reason(s)

for each:

_______ ____________________________________________________________

Has the student ever been detained in the office, assigned a restricted lunch, kept in for

recess/open periods, etc.? Please comment.

________________________________________________________________________

Please provide any other comments or important information regarding disciplinary issues and

consequences, as well as skills, positive characteristics and environmental supports:

________________________________________________________________________

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SAMPLE STUDENT ADVISOR FORM

Confidential

TO: __________________________________________________________

FROM: I&RS Team

DATE: __________________________________________________________

REFERENCE: __________________________________________________________

GRADE: __________________________________________________________

TEACHER: __________________________________________________________

The I&RS Team is in the process of gathering comprehensive information on the above-named

student. Your input will help the team develop an accurate profile of the student, as well as a

positive course of action.

Please return this form to _____________________________, by ________________________.

Academic Information:

Class rank: _______________________________ GPA: ___________________

Confidential Information:

 Yes  No Is there a copy of a psychological evaluation?

 Yes  No In addition to your role, are you aware of any kind of counseling

or therapy provided to the student, either currently or in the past?

Guidance Information:

Please provide any additional information you think will be helpful in the team’s assessment of

this student, including skills, positive characteristics and environmental supports. (Use the back

of the form if necessary.)

________________________________________________________________________

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SAMPLE SCHOOL NURSE/SCHOOL HEALTH FORM

Confidential

TO: ______________________________________________________

FROM: I&RS Team

REFERENCE: ______________________________________________________

DATE: ______________________________________________________

Please complete and return this form to the I&RS Team by: ________________________

Health History

Is the student currently taking any medication? If yes, please identify. _______________

________________________________________________________________________

Are you aware of any prior use of medication by the student? If yes, identify each

medication and condition treated. ____________________________________________

________________________________________________________________________

Are you aware of any medical or other condition that could interfere with the student’s

ability to perform in school? If yes, please describe the condition and its implications.

________________________________________________________________________

Health Assessment

Date of birth: _______________________

Height: _______________________ Weight: __________________

Vision: _______________________ Hearing: __________________

Skin: _______________________ Posture: __________________

Comments: ____________________________________________________________

Socialization

Observable behaviors: ________________________________________________

Behavioral changes: ________________________________________________

Comments: ____________________________________________________________

Physical Appearance (e.g., personal hygiene, fatigue, odor of smoke, attire)

________________________________________________________________________

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Sample School Nurse/School Health Form page 2 of 2

Visits to Nurse

Frequency/Number: ______________________________________________________

Reasons: ____________________________________________________________

Physical Education Excuses

Number: ____________________________________________________________

Reasons: ____________________________________________________________

Comments: ____________________________________________________________

Student Strengths

Skills __________________________________________________________________

________________________________________________________________________

Positive Characteristics ____________________________________________________

________________________________________________________________________

Environmental Supports ____________________________________________________

________________________________________________________________________

Other __________________________________________________________________

Other Pertinent Information

________________________________________________________________________

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INTERVENTION AND REFERRAL SERVICES

SAMPLE PARENT OR GUARDIAN LETTER

Confidential

NOTE: A personal interview with the student’s parent or guardian is always the

preferred method of contact. A personal conversation provides the opportunity for the

I&RS team to achieve the following objectives: 1) Provide support to the parent, 2)

Obtain important data, and 3) Develop a personal relationship. The Sample Parent

Questionnaire and Sample Parent Interview provides suggested questions to be explored

during the interaction. If personal notification is not possible, the district might consider

corresponding on school letterhead, accompanied by the Parent Questionnaire.

Mr. and Mrs. Parent

Home Lane

Nuclear-Extended Family, NJ 00000 Date

Dear Mr. and Mrs. Parent:

We have a new opportunity to provide assistance to your (daughter/son), (student’s full

name), through the school’s Intervention and Referral Services Team. Working in

cooperation with families, such as yours, enables the team to better understand how to

provide appropriate help to all of our students. Your knowledge and information

regarding (student’s first name) is most valuable to us in determining the best way to

proceed to support you and your child.

We invite you to either call (school representative for this case,) at (school

representative’s phone number) to discuss the matter, contact us to schedule a school

visit, or notify us of the best way to reach you. You can reach us between the hours of

____________ a.m. and ____________ p.m.

You can also help us by completing the attached Parent Questionnaire and returning it in

the enclosed envelope as soon as possible. The information you provide will help us to

determine a positive course of action, and will be strictly held in confidence.

Together, we can be more effective in helping your child achieve (his/her) potential.

Thank you for joining with us in this effort. We look forward to hearing from you.

Sincerely,

Edith Educator, School Representative

Enclosure

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SAMPLE PARENT QUESTIONNAIRE

Confidential

Student’s Name: ______________________________________________________

Parent’s Name: ______________________________________________________

Date: ______________________________________________________

1) What do you see as your child’s strengths?

2) What makes you proud of your child?

3) What does your child do that causes you the most concern?

4) What has been the most successful way to deal with your child’s behavior?

5) How can the school assist you with the concerns you have for your child or the

concerns that have been identified by the school?

6) In the past school year, has your child been seen by a doctor for anything other than a

common illness? If so, what caused you to take your child to the doctor?

7) Has your child been seen by a health professional for any physical or emotional

problem that interfered with your child’s success in school?

8) What other information about your child or your family situation would be helpful for

the school to know?

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Sample Parent Questionnaire page 2 of 2

Please use the following rating scale to answer the questions below:

Always (4) Most of the Time (3) Hardly Ever (2) Never (1)

__________ 1) Finishes what she/he begins.

__________ 2) Does the things I ask her/him to do.

__________ 3) Appears content.

__________ 4) Gets along with her/his friends.

__________ 5) Takes good care of her/his things.

__________ 6) Helps at home.

__________ 7) Makes me proud.

__________ 8) Obeys.

__________ 9) Shares.

__________ 10) Cries easily.

__________ 11) Talks back.

__________ 12) Hits.

__________ 13) Lies

__________ 14) Appears afraid.

__________ 15) Must be reminded to do things.

__________ 16) Gets hurt often.

__________ 17) Feels sick often.

__________ 18) Fights.

__________ 19) Ruins things.

__________ 20) Teases others frequently.

__________ 21) Threatens others.

__________ 22) Has trouble remembering things.

__________ 23) Accepts criticism.

__________ 24) I trust my child

__________ 25) I know what to expect from my child.

Please return the completed questionnaire in the enclosed envelope

to the following address:

Scholastic School

Academic Avenue

High Standards, NJ 00000

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INTERVENTION AND REFERRAL SERVICES

SAMPLE PARENT INTERVIEW

Confidential

STUDENT’S NAME: __________________________________________________________

PARENT’S NAME: __________________________________________________________

DATE: __________________________________________________________

1) Who are the people living in the home with the child? (NOTE: If the family is not a

“traditional,” nuclear family, follow-up on details.)

________________________________________________________________________

2) What, if any, important changes have occurred in the family structure?

________________________________________________________________________

3) How did your child react to the changes in family structure?

________________________________________________________________________

4) What, if any, serious illness or injury has your child had? Please identify and explain.

________________________________________________________________________

5) Is your child on medication? If so, please identify and explain the reason.

________________________________________________________________________

6) Have you noticed any significant changes in your child’s behavior?

________________________________________________________________________

7) Have you noticed any changes in your child’s eating habits?

________________________________________________________________________

8) Have there been any changes in your child’s sleeping habits?

________________________________________________________________________

9) Has your child experienced a bed-wetting problem?

________________________________________________________________________

10) Has there been any change in your child’s physical appearance?

________________________________________________________________________

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Sample Parent Interview page 2 of 3

11) How does your son/daughter spend his/her time?

________________________________________________________________________

12) Does your child share his/her thoughts regularly and openly share his/her thoughts with

you?

________________________________________________________________________

13) Does your child share his/her thoughts and feelings with anyone else? If yes, who?

________________________________________________________________________

14) Who initiates conversation between you and your child?

________________________________________________________________________

15) Does your child seem sad, moody or angry?

________________________________________________________________________

16) Have you ever had reason to suspect that your child has ever experimented with alcohol

or other drugs? Please explain.

________________________________________________________________________

17) Has your child ever talked about suicide? Please explain.

________________________________________________________________________

18) Have any of your son’s/daughter’s friends or any family members attempted or

committed suicide?

________________________________________________________________________

19) Has your child intentionally inflicted injury upon himself or others? Please clarify.

________________________________________________________________________

20) Has your child given away any of his/her important possessions lately?

________________________________________________________________________

21) Have you noticed any changes in your child’s room?

________________________________________________________________________

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Sample Parent Interview page 3 of 3

22) In the past few months, have you noticed any money, alcohol, prescription or over-the-

counter medications missing?

________________________________________________________________________

23) Has any member of your family (including grandparents, uncles, aunts, etc.) ever had a

problem with alcohol or other drugs?

________________________________________________________________________

24) Who assumes primary responsibility for discipline in your family?

________________________________________________________________________

25) How do you discipline your child?

________________________________________________________________________

What works best? ____________________________________________________

________________________________________________________________________

What do you find doesn’t work? _____________________________________________

________________________________________________________________________

26) What do you see as your child’s strengths?

________________________________________________________________________

27) What makes you proud of him/her?

________________________________________________________________________

28) What does your child do that causes you the most concern?

________________________________________________________________________

29) Has your child been seen by a health professional for any physical or emotional problems

that interfered with his/her success in school?

________________________________________________________________________

30) Is there anything you can think of that is going on that might be affecting your child?

________________________________________________________________________

31) Is there anything else you would like to share?

________________________________________________________________________

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INTERVENTION AND REFERRAL SERVICES

SAMPLE STUDENT SELF-ASSESSMENT SHEET

Confidential

Student Name: ___________________________________ Date: ____________

Check the column that most NEARLY applies to how you view yourself. There are no

right or wrong choices, so check what you REALLY do.

Always Usually

Sometimes

Hardly

Ever

Never

Volunteer in class

Demonstrate appropriate hall

behavior

Arrive to class on time

Do what I’m told

Behave for substitute teachers

Talk in class

Write on desks

Lean back in chairs

Chew gum in class

Throw objects in class

Hit or fight with other students

Have all materials for class

Help teacher when asked

Respectful toward others

Pay attention in class

Clean up desk area

Accept extra duties in class

Use lavatory time properly

Turn in found objects to teacher

or office

Obey the bus driver/crossing

guard

Copy work from others

Use abusive language

Destroy property

Take responsibility for my

actions

Seek help when needed

Break school rules

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INTERVENTION AND REFERRAL SERVICES

SAMPLE GENERAL RELEASE OF INFORMATION

CONSENT FORM

Confidential

I, _____________________________________________________________________,

(student or parent/guardian name)

authorize _______________________________________________________________

(name of individual/school disclosing information)

to disclose to ____________________________________________________________

(name or title of individual/organization

to whom the information is to be disclosed)

the following specific information from my record: ______________________________

________________________________________________________________________

_______________________________________________________________________.

This consent to disclose information may be revoked by me at any time, except to the

extent that action has already been taken in reliance thereupon.

This consent, unless expressly revoked earlier, expires upon (specify the date, event

and/or condition upon which consent expires):

Date: ______________________________________________________

Event: ______________________________________________________

Condition: ______________________________________________________

Student Signature: __________________________________ Date: ___________

Witness Signature: __________________________________ Date: ____________

Parent or Legal Guardian Signature: ______________________ Date: ____________

Legal Representative Signature: ______________________ Date: ____________

Specify Relationship of Legal Representative______________________________

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INTERVENTION AND REFERRAL SERVICES

SAMPLE I&RS ACTION PLAN FORM #1

Confidential

Person Requesting Assistance: ______________________ Meeting Date: _________________

Recorder Keeper’s Name: __________________________ Parent Notification Date: ________

Attendance: ________________________________ Case Coordinator: ______________

________________________________ ________________________________

1) Reason(s) for Request for Assistance (presenting educational problem[s]):

________________________________________________________________________

2) Problem Description

a) Behaviors of Concern (Specific, Observable, Descriptive, Objective, Factual):

________________________________ ________________________________

b) Background Information:

________________________________ ________________________________

c) General Nature of Problem: Competence ________ Compliance ________

3) Selected Problem(s) (problems that can and must be changed):

________________________________________________________________________

4) Student Strengths

a) Personal:

________________________________ ________________________________

b) Environmental:

________________________________ ________________________________

5) Behavioral Objective (short-term, achievable, measurable):

________________________________________________________________________

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Sample I&RS Action Plan Form #1 page 2 of 3

6) Prior Interventions

a) Outcomes/Effects of Past Efforts:

________________________________________________________________________

b) Reasons for Past Successes:

________________________________________________________________________

c) Reasons for Past Failures:

________________________________________________________________________

d) Benefits to the student and others involved with the student for not changing:

________________________________________________________________________

7) Alternative Solutions (brainstorming):

________________________________ ________________________________

8) Evaluation of Alternative Solutions (consider positive and negative consequences,

strengths and concerns, benefits to the student and family, benefits to the person

requesting assistance, success orientation, available resources):

________________________________ ________________________________

9) Selected Solution(s) (consider whether it is in a new form, maintains the student’s

dignity, develops the student’s internal locus of control over the problem, implementers

are capable of implementing it, empowers or provides relief for the person requesting

assistance):

________________________________________________________________________

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Sample I&RS Action Plan Form #1 page 3 of 3

10) Implementation, Monitoring and Support Plan*

Responsible Completion

Specific Tasks Resources Persons Date

________________________ _________________ _________________ _____________

* Should include, at a minimum, information on the type, frequency, duration and intensity of

interventions, assistance to implementers and required individual and family support services.

11) Follow-up and Evaluation Plan 12) Follow-up Meeting Date: _______

Responsible Completion

Specific Tasks Resources Persons Date

_______________________ _________________ _________________ _____________

________________________ _________________ _________________ _____________

13) Assessment of Team Effectiveness and Team Improvement Plan:

________________________________________________________________________

FOLLOW-UP MEETING

Date: __________ Next Meeting Date: __________ Record Keeper’s Name: ________________

Attendance: ________________________________ ________________________________

________________________________ ________________________________

14) Outcomes of I&RS Action Plan:

Strengths Areas of Improvement

________________________________ ________________________________

15) Recommended Action:

______No Further Action ______ Continue Original I&RS Action Plan

______ Modify Original I&RS Action Plan** ______ Refer to Child Study Team

______ Other Referral (specify)______________

(**If checked, complete steps 1-13, as appropriate.)

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INTERVENTION AND REFERRAL SERVICES

SAMPLE I&RS ACTION PLAN FORM #2

Confidential

… Worksheet …

Date: ____________________ Parent Notification Date: _______________

Person Requesting Assistance: ______________________ Problem Description:* _________________

I&RS Team Members: ______________________________ ____________________________________

______________________________ ____________________________________

______________________________ Goal Statement: ______________________

______________________________ ____________________________________

INTERVENTION FEASIBILITY AND EFFECTIVENESS SCALE

Directions: Please rate the feasibility, effectiveness and efficiency of each intervention being considered according to

the following rating scale criteria (each item should be rated on a scale of 1 to 5, where a score of 5 represents the most

favorable rating). After rating each proposed intervention on each criterion, a total score for each intervention is

obtaining by summing the rating given on each item. Each intervention should then be priority-ranked according to its

total score. Team ratings and rankings should be a product of team consensus. In most cases, the intervention ranked

first by the team is used by the individual(s) responsible for implementing the I&RS action plan to address the

identified problem. Use the following rating scale:

Potential Impact: The potential impact of this intervention is (1 = Low, 5 = High).

Successful Use: The use of this type of intervention has been successful (1 = Seldom, 5 = Often), or in

the case of a new intervention, the chance for success is (1 = Low, 5 = High).

Adaptive Skills: There is a high degree of comfort in the ability and skills of implementers to apply this

intervention (1 = Strongly Disagree, 5 = Strongly Agree).

Time Needed: The estimated time needed to implement this intervention to be effective is

(1 = Very Unreasonable, 5 = Very Reasonable).

Additional Resources: The number and types of additional resources needed to implement this intervention are

(1 = Very Unrealistic, 5 = Very Realistic).

Intervention Potential Successful Adaptive Time Additional Total

Alternative Impact Use Skills Needed Resources Score Rank

1) _____________________ _______ _______ _______ _______ _______ _______ _______

2) _____________________ _______ _______ _______ _______ _______ _______ _______

3) _____________________ _______ _______ _______ _______ _______ _______ _______

4) _____________________ _______ _______ _______ _______ _______ _______ _______

5) _____________________ _______ _______ _______ _______ _______ _______ _______

6) _____________________ _______ _______ _______ _______ _______ _______ _______

7) _____________________ _______ _______ _______ _______ _______ _______ _______

8) _____________________ _______ _______ _______ _______ _______ _______ _______

9) _____________________ _______ _______ _______ _______ _______ _______ _______

10) ____________________ _______ _______ _______ _______ _______ _______ _______

11) ____________________ _______ _______ _______ _______ _______ _______ _______

12) ____________________ _______ _______ _______ _______ _______ _______ _______

13) ____________________ _______ _______ _______ _______ _______ _______ _______

14) ____________________ _______ _______ _______ _______ _______ _______ _______

15) ____________________ _______ _______ _______ _______ _______ _______ _______

* Please attach all appropriate documentation used to verify the problem description and all evidence of prior

interventions used to solve the problem.

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Sample I&RS Action Plan Form #2 page 2 of 2

… Action Plan …

Completion

Implementation Strategies/Activities Person(s) Responsible Time Frame

_________________________________ _____________________ ____________

Completion

Monitoring Strategies Person(s) Responsible Time Frame

_________________________________ _____________________ ____________

Completion

Outcome Evaluation Strategies Person(s) Responsible Time Frame

_________________________________ _____________________ ____________

Evaluation of Intervention Completion

Feasibility and Effectiveness Person(s) Responsible Time Frame

_________________________________ _____________________ ____________

Completion

Follow-up and Redesign Plan Person(s) Responsible Time Frame

_________________________________ _____________________ ____________

Source: Idol, L. & West, J.F. (1993). Effective Instruction of Difficult-To-Teach Students.

Adapted by permission.

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INTERVENTION AND REFERRAL SERVICES

SAMPLE I&RS ACTION PLAN FORM #3

Confidential

Date: _______________________ Parent Notification Date: _____________

Person Requesting Assistance: ____________________________________________________

I&RS Team Members: __________________ __________________ _________________

__________________ __________________ _________________

Problem Description:*

Prior Interventions Used to Solve the Problem:**

________________________________________________________________________

Goal Statement

:____________________________________________________________

________________________________________________________________________

Alternative Interventions/Solutions How Feasible and Effective Rank

1. __________________________________ _______________________ ______

__________________________________ _______________________ ______

2. __________________________________ _______________________ ______

__________________________________ _______________________ ______

3. __________________________________ _______________________ ______

__________________________________ _______________________ ______

4. __________________________________ _______________________ ______

__________________________________ _______________________ ______

5. __________________________________ _______________________ ______

__________________________________ _______________________ ______

6. __________________________________ _______________________ ______

__________________________________ _______________________ ______

* Please attach all appropriate documentation used to validate the problem description and

any supportive evidence of prior interventions used to solve the problem.

** In most cases, the intervention ranked first by the team (with concurrence of individuals

responsible for implementation) will be used to address the identified problem.

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Sample I&RS Action Plan Form #3 page 2 of 2

Implementation Steps* Person(s) Responsible Time Frame

_____________________________________ ________________________ _____________

* Includes any recommendations for accessing school resources or community-based health or social

services.

How Will the Plan be Monitored? Persons Responsible Time Frame

_____________________________________ ________________________ _____________

How Will Student Progress be Evaluated?

_____________________________________ ________________________ _____________

Team Evaluation of Intervention Effectiveness Date and Time of I&RS Follow-up Meeting**

_____________________________________ _______________________________________

_____________________________________

** Should occur within 2-4 weeks of the beginning of the I&RS Action Plan.

Source: West, Idol and Cannon (1989). Collaboration in the Schools: Communication, Interactions and Problem

Solving. Adapted by permission.