Northwest Special Education Cooperative
_____________________________________________________________________
310 N. West St., Room 137, Elizabeth, IL 61028
Phone: 815-599-1947
Fax: 815-858-2195
www.northwestcoop.com
Referral Form for NWSE Behavior Consultant Services
The referral form is to be completed prior to the initial meeting with the Behavior Consultant. The referring
professional will need to obtain the signature of the student’s parent/guardian and the building administrator
prior to forwarding it to the Behavior Consultant. Completed referral forms can be faxed or scanned and
emailed to:
Email Scan: [email protected]
Fax: (815)858-2195
Background Information
Student Name:____________________ DOB:_______________ Sex: ____M ____F
Grade:_________
Serving District:__________________
Does the individual currently have an IEP? _____Y _____N
Primary Eligibility:__________________
Secondary Eligibility:_________________
Does the individual currently have a Behavior Intervention Plan? _____Y _____N
Current Medical Diagnoses and Know Medications:__________________________
Current Related Services (circle): OT
PT
S/L SW Hearing Vision Paraprofessional
General Education Teacher Name:___________________________________
General Education Teacher Email:___________________________________
Special Education Teacher Name:____________________________________
Special Education Teacher Email:____________________________________
Target Behavior(s) of Concern: (Identify no more than two primary behaviors)
_____Verbal Aggression
______Physical Aggression
_____Non-Compliance
_____Off-Task
_____Other (specify)
Observationally Define Listed Target Behaviors: (What does the behavior look like? Example: Hides
under desk, spits at staff, refuses by turning body away from staff, etc.)
Target Behavior #1:
Target Behavior #2:
Meeting the special needs of all students in Northwest Illinois
_________________________________________________________________________________________________
Serving Dakota, East Dubuque, Galena, Lena-Winslow, Orangeville, Pearl City, River Ridge, Scales Mound, Stockton, Warren, and West Carroll
Northwest Special Education Cooperative
_____________________________________________________________________
310 N. West St., Room 137, Elizabeth, IL 61028
Phone: 815-599-1947
Fax: 815-858-2195
www.northwestcoop.com
Additional Information on Target Behaviors
Target
Behavior
Frequency
Duration
Intensity
Antecedents
Consequences
How many times per
week, day, lesson,
minute, etc. behavior
occurs
How long does an
incident of the
behavior last?
(see rating scale
below)
What typically
happens right before
the behavior?
What typically
happens following the
behavior?
Behavior #1
Behavior #2
Intensity: Mild: little risk to safety or learning environment of self, property, or others. Moderate: risk to self
or others that disrupts learning environment for periods of time less than 10 minutes or safety of self or others
without leaving marks/bruises. Severe: significant risk to safety of self or others engaging in behaviors that
leave marks/bruises or disrupts learning environment for more than 10 minutes of instructional time in a single
incident.
Are there times that you notice the behaviors occur more frequently?
Behavior 1:
Behavior 2:
Are there times that the target behaviors do not occur?
Behavior 1:
Behavior 2:
Meeting the special needs of all students in Northwest Illinois
_________________________________________________________________________________________________
Serving Dakota, East Dubuque, Galena, Lena-Winslow, Orangeville, Pearl City, River Ridge, Scales Mound, Stockton, Warren, and West Carroll
Northwest Special Education Cooperative
_____________________________________________________________________
310 N. West St., Room 137, Elizabeth, IL 61028
Phone: 815-599-1947
Fax: 815-858-2195
www.northwestcoop.com
Do parents report engagement in the behaviors at home?
Behavior 1:
Behavior 2:
Has the school social worker, counselor, or educational psychologist offered strategies/interventions?
What positive/preventative strategies have been used for the behaviors and how effective were they?
Behavior 1:
Behavior 2:
Were previously listed interventions were consistently implemented as recommended?
Who are the target behaviors directed at? (self, peer, staff, not at a person, etc.)
Behavior 1:
Behavior 2:
Does the student have any special interests?
Is there any additional relevant information to note?
Meeting the special needs of all students in Northwest Illinois
_________________________________________________________________________________________________
Serving Dakota, East Dubuque, Galena, Lena-Winslow, Orangeville, Pearl City, River Ridge, Scales Mound, Stockton, Warren, and West Carroll