MTSS-B Student Referral Form

The MTSS-B Student Referral Form gives a school a structured, repeatable process for referring a student for social-emotional-behavioral (SEB) support, from the first documented concern through intervention and follow-up. It keeps referring teachers, the MTSS team, and everyone who supports the student working from the same information and the same plan.

The form moves through four stages:

• Pre-Referral Checklist: Before referring, the teacher documents what's already been tried, cumulative file review, team collaboration notes, universal screening data, and Tier 1 classroom accommodations, plus a checklist of specific supports already attempted (proximity, redirection, visual schedule, breaks, and more)
• Area(s) of Concern: The team selects the top three concerns from a shared list (aggression, non-compliance, withdrawal, anxiety, and others) and describes the context and likely function behind the behavior
• Skill Building & Intervention Plan: The team selects target skills to build (self-regulation, executive functioning, accessing help, and others) and chooses an intervention approach, such as Check-In Check-Out, a Behavior Contract, a Simple BIP, or a Mental Health Referral
• MTSS Team Plan & Follow-Up: The team documents the specific goal, intervention details, who's responsible, session frequency, and data collection method, then revisits at a follow-up meeting to rate progress and decide whether to continue, update, or fade the plan

Because the pre-referral checklist is built into the form itself, it also functions as a gate, ensuring Tier 1 strategies are documented and attempted before a student moves to team-level intervention.

Download the MTSS-B Student Referral Form

In Behavior Advantage: Use the Area(s) of Concern and Intervention Plan sections to inform whether a Simple BIP, full FBA/BIP, or other Behavior Advantage tool is the right next step for the student.