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Behavior RTI Online Electronic Student Referral Form (Google Form)

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Simplify your Behavior Response to Intervention (BRTI) student referral process with our electronic, online referral form created using Google Forms. Easily copy the form to your Google Drive and streamline your BRTI process for increased efficiency and effectiveness. Improve your school's behavior management today!


With this form, teachers can complete the questionnaire online and make electronic referrals for their students. Whenever a student is recommended, you'll receive a notification. This form not only allows you to receive student referrals electronically but also makes it easier to collect data for your BRTI program.


This form offers several benefits to help streamline the referral process and improve data collection for your BRTI program. With this form, you can easily organize and collect all necessary information in one place, eliminating the need to remember which teacher referred which student. The form also guides teachers through the necessary information to submit, ensuring that no questions are forgotten. Additionally, you'll get a general idea of the behaviors that teachers are concerned about for each student.


Once you've downloaded and set up the form, you have the option to edit it to fit your school's specific needs. Afterward, simply place a link to the form in a convenient location for your staff to access, such as your email signature or your school's website page.


When teachers access the form, they will see a clean, user-friendly interface. Meanwhile, you'll have access to a spreadsheet containing all the information submitted by staff members about students with behavior concerns. At the end of the year, you can use the data summary to target school-wide behavior goals and improve your BRTI program.


The following questions are included on the BRTI Referral form:

1. Student Name *

2. Current Grade *

3. DOB *

4. Name of the person requesting Behavior RTI service

5. Role of person requesting Behavior RTI services *

6. Date of referral for BRTI *

7. List 3 strengths that the student has: *

8. Student History - Come to the initial meeting prepared to discuss any items checked below. *

9. Teacher Observations *

10. Please check MAJOR behavior concerns: *

11. How long has the behavior(s) been present? *

12. How often does the behavior(s) occur? *

13. How severe is the behavior(s)? *

14. How long does the behavior(s) last? *

15. Where does the problem occur? (Check all that apply) *

16. Are there any events or conditions that immediately precede the problem? (Check all that apply) *

17. Why do you think these problems occur? (Check all that apply) *

18. How many times has this student been written-up for disciplinary action from administration this school year? *

19. What interventions or strategies have been tried or are currently in place? *

20. Date(s) of parent contact(s) regarding problem behavior(s) *


Streamline your referral process and simplify data collection with our user-friendly form today!


You must have a Google account to use this. Don’t have one yet? Setting up a Google account is easy and free!


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Questions?Β I'm here for you! Please contact me atΒ michelle@creativecounselingresources.com


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