Building INtervention Team Referral Form Secondary
General Information
Date of Referral
Student’s Name	Student’s Grade
Teacher’s Name	Subject Area
Area(s) of Concern(please check):
Academic Choose an item. If other, please describe:	Behavior: Choose an item. If other, please describe:	Other: If other, please describe:
Rate student’s performance on all statements:
Academic Performance	Above Average	Average	Below Average
Student understands material taught
Student shows appropriate effort or motivation
Student performs well on tests
Student completes work in class
Student completes homework assignments
Student completes work within the time allotted in class
Student comes to class prepared
Student is able to sustain focus/attention
Student is compliant in class
Student interacts well with peers
Student attends class regularly
Student comes to class on time
Estimated Letter Grade
A B C D F
Student’s Strengths:	Student’s Challenges:
When do challenges/concerns occur least often?	When do challenges/concerns occur most often?