HS-SAP Referral Form

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Clarion Area Jr. Sr. High

Email *

Instructions

The following form is to be used when a student shows signs of distress in any of the following areas; Behavior, health, academics and/or attendance. If you feel a student is a danger to themselves or others, please contact an administrator immediately.

Name of Student being referred: *

Date

YYYY

Referral Source Category *

Administration

Teacher

Parent/Guardian

Peer

Self

Attendance Office

Other

Individual Referring (optional)

Academic Performance *

Decrease in class participation

Short attention span, easily distracted

Drop in grades / lower achievement

Poor short term memory

Does not complete assignments

Required

Academic Performance Current grade/comments

Health

Deteriorating personal appereance

Frequent cold like symptoms

Glassy or blood shot eyes

Unexplained/frequent physical injuries/bruises

Sleeping in class

Odor of smoke

abnormal weight loss

Additional Health Comments

School/Class Attendance (# of Absences/Tardies)

Class Attendance

Frequent requests to leave classroom

Late to class

Behavior

Defiance of rules

Argumentative/defensive

Verbally abusive

Attention-getting behavior

Exhibits self-abusive behavior

Irresponsible; blaming; denying

Cheats/lies

Inappropriate language, gestures

Negativity

Change in Friends

Withdrawn, difficulty relating to others

Talks, writes about drugs

Lethargic

Have you contacted the parent/guardian regarding concerns? *

Yes

If you contacted parent/guardian, what was the date and outcome?

Additional Comments Behavior

Student's Strengths

Additional Comments

Send me a copy of my responses.

Submit

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