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Middle School Student Assistance Program (SAP) Initial Referral Form (22-23)
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Email
*
Your email
Student Name:
*
Your answer
Grade
*
6
7
8
Date:
*
MM
/
DD
/
YYYY
Your Name:
*
Your answer
Academic Behaviors
Declining quality of work
Declining grades
Homework not handed in
Inattentive (specify behavior - below)
Declining motivation
Disruptive in class (specify behavior - below)
Consistent quality of work
Consistent grades
Homework consistently completed
Attentive
Well motivated
Contributes to classroom climate
If inattentive or disrupted in class, specify behavior:
Your answer
Social Behaviors
Negative responses/attitude
Negative change in friends/peer group
Consistently seeks adult approval
Withdrawn/loner
Struggle for achievement/perfectionist
Difficulty accepting mistakes/criticism
Dishonest
Increasing non-involvement
Frequently absent
Physical agression
Verbal aggression
Talks about substance abuse
Positive friends/peer group
Appropriate interactions with adults
Positive relationships with peers
Content with level of achievement
Honest
Positively involved in school activities
Regular attendance
Other concerns or strengths:
Your answer
Strategies you have attempted (Check all that apply)
Student Conference
Student Contract
Referral to Principal
Referral to Counselor
Telephoned Parent
Parent Conference
If checked any above, please add date.
Your answer
Please list any other strategies you have attempted so far in dealing with your concern:
Your answer
Policy Violation (For Administration/Counselor Use)
Your answer
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