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Chapter 3

Initial Request For Intervention Team Review Form

Student _______________________________ Date________________________________Birth Date _____________________________ Grade _________ ID# ________________School _______________________________ Teacher _____________________________Parent(s) ______________________________ Phone # ____________________________Language(s) spoken at home _______________________________________________________Meeting requested by _____________________________________________________________ Problems noted in

What should the student be able to do? (Attach work samples if additional information is needed.)

How have concerns been discussed with the parent?

Who should attend the meeting? Who will contact them?Administrator General Education Teacher Parent Teacher or Counselor Psychologist Special Education Teacher Social Worker AdministratorSpeech and Language Clinician Reading Specialist School Counselor

Problem Solving Meeting Date ______________________ Time ________________

Reading Math Writing Social/Behavioral

68 • Council for Exceptional Children

Intervention Team Problem-Solving Meeting Form

Student ______________________________ Date________________________________Birth Date ____________________________ Grade _________ ID# ________________School _______________________________ Teacher _____________________________Parent(s) ____________________________ Phone # ____________________________Language(s) spoken at home _______________________________________________________Meeting requested by _____________________________________________________________ Current services student is receiving:

Student assets:

Statement of Concern: What academic or behavior problems is the student experiencing? (Describe in observable/measurable terms)

What interventions have already been tried?

What should the student be able to do?

Parent Present: Yes ___________ No ___________Parent Input:

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What School Counselors Need to Know About Special Education and Students With Disabilities • 69

Chapter 3

Research-based intervention/strategy Start date

Frequency/ duration Person(s) responsible

Progress monitoring assessment & schedule

Intervention Team Problem-Solving Meeting Form (continued)

Goal Statement

By (date)____________________ the student will ____________________________________________________________________________________________________________________.

Possible solutions/research-based interventions:

Action PlanBrief description of Action Plan:

Date of follow-up meeting to evaluate progress _________________________

Progress Monitoring/Evaluation Effect of Intervention on Student Academic and Behavioral Performance:

Review of Action Plan and Further Disposition (Include data sheets):

Progress made. Continue, discontinue, or alter plan ________________________________

Additional interventions needed ______________________________________________

Refer to Child Study for assessment__________________________________________

Parent requested referral to special education___________________________________

Signatures: Team Leader___________________ Teacher________________________________

Parent ________________________ Administrator ___________________________

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