LEVEL 3 Top of Page
REFERRAL PROCESS
Click here for an editable Level 3 - Referral Process Form using MS Word.

Student____________________ Teacher________________________
Level 3 Intervention beginning on Date___________________________

1. Please check behavior(s) which led to this referral. Please rate the frequency and severity of the behaviors on a scale of 1 to 3. A score of 1 would indicate a higher level of severity and a higher frequency of occurrence. (Please bring evidence which supports your rating.)

BEHAVIORS	FREQUENCY	SEVERITY
Lack of academic progress	_________	_________	_________
No homework	_________	_________	_________
Failure on tests	_________	_________	_________
Off-task	_________	_________	_________
Poor organizational skills	_________	_________	_________
Social/Emotional problems	_________	_________	_________
Aggressive behavior	_________	_________	_________
Bullying	_________	_________	_________
Acting out	_________	_________	_________
Hyperactivity	_________	_________	_________
1. Are there specific times or situations when the problem occurs most?
__________________________________________________________________
__________________________________________________________________

2. Please identify previous interventions that were helpful and indicate the extent of progress.
__________________________________________________________________
__________________________________________________________________

3. Please identify previous interventions that were not helpful.
___________________________________________________________________
AFTER COMPLETING THIS FORM, PLEASE SCHEDULE AN IAT REFERRAL CONFERENCE WITH YOUR PRINCIPAL. PLEASE BRING THE FOLLOWING DOCUMENTATION TO THAT CONFERENCE:
A printout of the Level 1, 2, and 3 Intervention forms
Samples of student work
Evidence of previous interventions

khearing

2011-12-06

Joe Winnenberg