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Program Planning Team: Please complete this checklist before making a referral for Behaviour Support or the Behaviour Intervention Resource Teacher (BIRT) program.
Student: ______________________________________ Date: __________________________________
Briefly describe any strategy implemented in the classroom/school and the outcomes on the student’s behavior.
Services Presently Being Accessed
_____ School Psychology _____ Resource _____Schools Plus
_____ Speech-Language Pathology _____ Learning Disabilities _____ Learning Center
_____ Guidance _____ Social Work _____ Pediatrician
_____ Relays _____ Youth Peers _____ Family Services
_____ Child Welfare _____ Family Place Resource Center
Other(s): ___________________________________________________________________________________________________
Where are the Strategies Documented in Tienet? ___________________________________________________________
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