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Bethel Park High School Student Assistance Referral Form 2020-21
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* Indicates required question
Email
*
Your email
Referral Date
*
MM
/
DD
/
YYYY
Teacher Name
*
Your answer
Student Name
*
Your answer
Student Grade
*
9
10
11
12
Required
Reason for Referral
*
Class Cuts/Attendance Concerns
Behavior Concerns
Emotional Concerns
Social Concerns
Drug and Alcohol Concerns
Academic Concerns
Other:
Required
Provide details for reason for referral:
*
Your answer
Interventions Attempted
*
Check the appropriate line to indicate the steps you have taken to correct the behavior(s).
Telephoned/Email Parent
Parent/Teacher Conference
Referred for Discipline
Referred to Principal
Referred to Counselor
Referred to Social Worker
Adapted Curriculum
Referred to Nurse
Classroom Interventions (ie, Move their seat, 1:1 with student, etc)
Required
Dates/frequency of attempted interventions
Your answer
List Any Modifications to the Student's Curriculum
Your answer
Submit
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