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Teacher Name
First Name
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Student Name
First Name
Last Name
Student Grade
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2nd
3rd
4th
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Student Age
Which Apply to Student
Special Education Student
ESOL
EIP
RTI
TAG
Speech and Language
Diagnosed ADHD
Internalizing Behaviors
Exhibits sadness or depression
Teased or bullied by peers
Sleeping
Does not stand up for self
Doesn't participate
Self-injury
Acts fearful
Withdrawn/isolated
Externalizing Behaviors
Out of seat/assigned area
Defiance
Inappropriate language
Talking out of turn
Eloping
Chronic absenteeism/tardies
Frequent illness/ trips to nurse
Fighting/physical agression
Strategies Used
Successful
Somewhat Successful
Unsuccessful
Reteaching of behaviors
Tangible recognition for expected behaviors
Multiple opportunities to practice
Self-monitoring
4:1 positive feedback
Relaxation/coping techniques
Modified assignments
Counselor assistance
Parent/guardian contact
Scheduled breaks
Additional Strategies not Listed in Table
Traumatic Event
Parent Communication
Additional Information
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