LCMR School District

Initial Request for Assistance Form

* 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 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.

Spoke to student privately after class

Explained class rules and expectations

Explained my concerns

Gave student help after class/school

Changed students seat

Spoke/emailed with parent/guardian

List Dates That You Spoke With Parent / Guardian (If Applicable)

Gave student special work at his/her level

Held conference with parent/guardian

Sent home notices regarding behavior/work

Arranged an independent study program

Gave student extra attention

Assigned student detention

Spoke to students guidance counselor

Spoke to students assistant principal

Other

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687 Route 9 • Cape May, NJ 08204 • (609) 884-3475