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Intervention and Referral Services
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Intervention and Referral Services

Initial Request for Assistance Form

1) From*
2) Date*
3) Student*
4) Reasons for Request for Assistance (Must be for school-based issues, i.e. academics, behavior, school health)
5) Specific and Descriptive Observed Behaviors (Hearsay or subjective comments will not be accepted)
6) Please list all communications you have had with the students parent/guardian

Prior Intervention Checklist:

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

7) Spoke to student privately after class
8) Explained class rules and expectations
9) Explained my concerns
10) Gave student help after class/school
11) Changed students seat
12) Spoke/emailed with parent/guardian
13) List Dates That You Spoke With Parent / Guardian (If Applicable)
14) Gave student special work at his/her level
15) Held conference with parent/guardian
16) Sent home notices regarding behavior/work
17) Arranged an independent study program
18) Gave student extra attention
19) Assigned student detention
20) Spoke to students guidance counselor
21) Spoke to students assistant principal
22) Other
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