Please answer the questions below so that we will be better prepared at the initial RtI meeting to talk with you about the needs of this student.
GENERAL INFORMATION
Date:
Phone #
Date Parent was Contacted About RtI Referral :
By Whom?
Please note any medical or health concerns for this student.
How is the student’s attendance this year?
Current School or Agency Support Services/Programs in place for this student (e.g., counseling, tutoring, etc.):
What are several strengths, talents, or specific interests for this student?
INSTRUCTIONAL INFORMATION
What makes this student difficult to teach? List any academic, social, emotional, or medical factors that seem to negatively affect the student’s progress. (If the problem is primarily behavioral, how often does the problem occur, how intense is it, and for how long does the problem last? If the problem is primarily academic, what specific deficits does the student have in particular academic skills or competencies?)
How do this student’s academic skills compare to those of the ‘average’ children in your classroom? (e.g., how does the student compare to peers in reading, math, writing, organizational skills?):
What is this child’s estimated current reading level?
List any other general information about the students’ academic levels or abilities (e.g., test results) that may shed light on your referral concern:
PROBLEM IDENTIFICATION INFORMATION
Please state your primary concern/reason for this referral.
Interventions Attempted: Please describe specific attempts that you or others have made this year to meet this student’s academic, social, and/or emotional needs:
Intervention 1
Dates Began-Ended
Person(s) Responsible
Outcome
Intervention 2
Dates Began-Ended
Person(s) Responsible
Outcome
Intervention 3
Dates Began-Ended
Person(s) Responsible
Outcome
If the referral concern is in academics, how much time during the period/day does the student receive instruction in the area(s) of difficulty?
When have you observed the problem occurring most?
Are the settings or situations in which the problem is less severe or minimized? If so, when?
Please list others whom you would like to receive an invitation to the initial RIST/RtI meeting:
Please list others whom you would like to receive a copy of the RIST/RtI Intervention Plan(s) after the initial meeting: