St.

Louis Park School District #283

CRISIS INTERVENTION REPORTING FORM
Student Name: XX Grade: 1
st
DOB: XX
Address: XX
Parent/Guardian Name: XX Phone: XX
Date/Time of Incident: 9/6/2013 at 2:10pm
Person Making Report: Kari Schwietering Referred by: Teacher
Description of Concern (i.e. presenting problems, actions that have occurred):
Student appeared to become frustrated with class assignment. He was asked to
leave the classroom to go to solution room. Student threw plant on the floor and
refused to leave. Behavior Aide was called, class evacuated and student continued
to escalate.
Physical/Emotional State of Child (self harm thoughts, is there a plan for
suicide, verbal/nonverbal communication): Student jumped on the table and
began yelling and throwing items, CPI (Crisis Prevention Intervention) team was
called. Student continued throwing and started to try to kick and punch the CPI
team. CPI single and two person holds were used. Student was very upset,
enraged and threatened adults. He continually tried kicking, hitting, punching, and
biting every time the hold was released.
Action Plan (immediate intervention taking place): Worked with staff to set up
plan to support student.
Parent contact (record details of parent contact, information provided to
parent, date contacted, referrals made to parent, parents stated plan for
student): Parent was called by Principal Nielsen. Parent was able to calm student.
Parent, Principal and student debriefed situation. End of day, mediation with
teacher, parent and student occurred.
Follow-up (other pertinent data, referral to outside agency, teacher
consultation): Mom stated that she would be taking student to specialist.
Copy to: Cumulative File Staff involved in intervention: Counselor File
Revised 7/2012