Behavior Referral Form Student Name: _______________________________Teacher: ____________________________ Room #: _________Phone Ext_________________ Grade/ Age: ___________________________ Date: ____________________ Time: From _________To _________ Subject: ________________ Is the student identified as EC? Yes No CRISIS Behavior: Perceived Intensity: Is the student injuring himself or Yes No low med high risking harm? Is the student injuring another student?Yes No low med high (incl. inappropriate sexual advances) Is the student destroying property? Yes No low med high Has there been a sudden unexplainable change In mood or affect of the student? Yes No If the student displays any of the above crisis behavior contact your EC Facilitator or SAP Chair. Check all descriptions below that apply to the behavior(s) observed and rate the intensity: Check if applies Description of Behavior Circle Perceived Intensity 1= low 3=med 5=high Not following directions / Non-compliance 1 2 3 4 5 Talking out / Disrupting the class Making excessive noise / Yelling Swearing / Making negative comments Inappropriate undressing Moving out of area / Leaving the room Throwing objects Making faces / Gestures Arguing with staff Displaying off-task behavior for more than 5 min Threatening others physically or verbally Other Completed By: _________________________________________ Position: ________________________ Revised 10/12/06