Thank you for considering purchasing the Behavior Response To Intervention (BRTI) Referral Form. This is a form created using Google forms and can be copied to your Google Drive.
Using this form, teachers can complete the questionnaire online and make a referral electronically. You will receive a notification every time a student is recommended. Not only will you be able to receive student referrals electronically, but also collecting data for your BRTI program will be made easy!
- Organize and streamline the referral process.
- Collect all of the information you need in one handy place.
- No need to try to remember which teacher referred which student to you as you met in passing in the hallway.
- Never forget a question to ask. The form guides teachers through what information to submit.
- Get a general idea of what the behaviors are that the teachers are concerned about for each student.
After you've downloaded these instructions and set-up your form you have the option to edit it any way you'd like. Once you're finished, simply place a link to the form in a convenient place for you staff to access (such as your e-mail signature or your page on your school's website).
Teachers will see a nice neat online form. You will see a spreadsheet detailing all of the information staff members have submitted about students with behavior concerns. At the end of the year, use the summary of data to target school-wide behavior goals.
The following questions are included on the BRTI Referral form:
1. Student Name *
2. Current Grade *
3. DOB *
4. Name of the person requesting Behavior RTI service
5. Role of person requesting Behavior RTI services *
6. Date of referral for BRTI *
7. List 3 strengths that the student has: *
8. Student History - Come to the initial meeting prepared to discuss any items checked below. *
9. Teacher Observations *
10. Please check MAJOR behavior concerns: *
11. How long has the behavior(s) been present? *
12. How often does the behavior(s) occur? *
13. How severe is the behavior(s)? *
14. How long does the behavior(s) last? *
15. Where does the problem occur? (Check all that apply) *
16. Are there any events or conditions that immediately precede the problem? (Check all that apply) *
17. Why do you think these problems occur? (Check all that apply) *
18. How many times has this student been written-up for disciplinary action from administration this school year? *
19. What interventions or strategies have been tried or are currently in place? *
20. Date(s) of parent contact(s) regarding problem behavior(s) *
You must have a Google account to use this. Don’t have one yet? Setting up a Google account is easy and free!
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