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