1. 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 =med 5=high
Not following directions / Non-compliance
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