Intervention & Referral Services (I&RS) - Request for Assistance
The overall I&RS process begins when a staff member or parent concludes that a student who exhibits a learning, behavior, health, or attendance issue and needs assistance. 

Please respond to the following to the best of your ability.  
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Email *
STUDENT'S Last Name *
STUDENT'S First Name *
Grade Level of student:
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PARENT'S First & Last Name:
REASON FOR REQUEST  (Check all that apply)
Have you contacted your child's teachers regarding specific concerns?  Please list the date(s), teacher(s), and the results.
To the best of your knowledge, select all previously attempted interventions.
To the best of your knowledge, please provide feedback on your child's academic performance.  (Check all that apply)
To the best of your knowledge, please provide feedback on your child's attendance. (Check all that apply)
What does your child tell you about his or her school experience? *
What are your concerns for your child that may impact his or her learning and/or behavior? *
How can the school assist you with the concerns you have for your child or the concerns that have been identified by the school? *
In the past school year, has your child been seen by a doctor or health professional for a visit other than a common illness?  If so, please explain if the reason for visit may have interfered with your child’s success in school? *
What other information about your child or your family situation would be helpful for the school to know? *
There 40 developmental assets identified as building blocks of healthy development that help young people grow up healthy, caring, and responsible.  The first 20 are EXTERNAL ASSETS and the last 20 are INTERNAL ASSETS.  Please select YES/NO/UNSURE.
Yes
No
Unsure
Family Support - Family life provides high levels of love and support.
Positive family communication - Young person and her or his parent(s) communicate positively, and young person is willing to seek advice and counsel from parents.
Other adult relationships - Young person receives support from three of more nonparent adults.
Caring Neighborhood - Young person experiences caring neighbors.
Caring school climate - School provides a caring, encouraging environment.
Parent involvement in schooling - Parent(s) are actively involved in helping young person succeed in school.
Community values youth - Young person perceives that adults in the community value youth.
Youth as Resources - Young people are given useful roles in the community.
Service to Others - Young person serves in the community one hour or more per week.
Safety - Young person feels safe at home, school, and in the neighborhood.
Family boundaries - Family has clear rules and consequences and monitors the young person’s whereabouts.
School Boundaries - School provides clear rules and consequences.
Neighborhood boundaries - Neighbors take responsibility for monitoring young people’s behavior.
Adult role models - Parent(s) and other adults model positive, responsible behavior.
Positive peer influence - Young person’s best friends model responsible behavior.
High expectations - Both parent(s) and teachers encourage the young person to do well.
Creative Activities - Young person spends three or more hours per week in lessons or practice in music, theater, or other arts.
Youth Programs - Young person spends three or more hours per week in sports, clubs, or organizations, at school and/or in the community.
Religious Community - Young person spends one or more hours per week in sports, clubs, or organizations at school and/or in the community.
Time at home - Young person is out with friends “with nothing special to do” two or FEWER nights per week.
Achievement Motivation - Young person is motivated to do well in school.
School Engagement - Young person is actively engaged in learning.
Homework - Young person reports doing at least one hour of homework every school day.
Bonding to school - Young person cares about her or his school.
Reading for Pleasure - Young person reads for pleasure three or more hours per week.
Caring - Young person places high value on helping other people.
Equality and social justice - Young person places high value on promoting equality and reducing hunger and poverty.
Integrity - Young person acts on convictions and stands up for her or his beliefs.
Honesty - Young person “tells the truth even when it is not easy.”
Responsibility - Young person accepts and takes personal responsibility.
Restraint - Young person believes it is important not to be sexually active or to use alcohol or other drugs.
Planning and decision making - Young person knows how to plan ahead and make choices.
Interpersonal Competence - Young person has empathy, sensitivity, and friendship skills.
Cultural Competence - Young person has knowledge of and comfort with people of different cultural/racial/ethnic backgrounds.
Resistance skills - Young person can resist negative peer pressure and dangerous situations.
Peaceful conflict resolution - Young person seeks to resolve conflict nonviolently.
Personal power - Young person feels he or she has control over “things that happen to me.”
Self-esteem - Young person reports having a high self-esteem.
Sense of purpose - Young person reports that “my life has a purpose.”
Positive view of personal future - Young person is optimistic about her or his personal future.
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A copy of your responses will be emailed to the address you provided.
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