School Counselor Tier 2 Intervention Referral

School Counselor Tier 2 Intervention Referral — Form Fields

This education template includes 11 fields. Teachers refer students for Tier 2 counseling or behavior support interventions within the MTSS framework. Free to customize and use on ZenBuild.

• Referring Teacher Name (text, required)
• School Email (email, required)
• Student Name (text, required)
• Student Grade (text, required)
• Primary Concern (dropdown selection, required) — options: Academic Performance, Attendance, Behavior, Social-Emotional, Peer Relationships, Family Stress
• Observable Behaviors or Concerns (long text, required)
• Duration of Concern (text, required)
• Tier 1 Supports Already Tried (dropdown selection, required) — options: Classroom Check-ins, Parent Contact, Behavior Chart, Small Group Support, None
• Parent or guardian notified of this referral (checkboxes, required)
• Urgency Level (dropdown selection, required) — options: Low, Moderate, High, Crisis - Refer to Administrator
• Additional Notes (long text, optional)