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SnackPacks Referral Form
Samaritan Community Center
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Date of Referral
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MM
/
DD
/
YYYY
Student's Last, First Name
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Your answer
Grade
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Choose
9
10
11
12
Name/Title of person referring the student:
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Your answer
Referral must include at least two items from each category or 6 factors total.
Behavior that demonstrated food insecurity:
Rushing food lines
Extreme hunger on Monday morning
Eating all of the food served
Lingering around or asking for seconds
Comments about not having enough food at home
Other:
School Performance:
Excessive absences and/or tardiness
Chronic sickness
Short attention span/inability to concentrate
Chronic behavior that leads to disciplinary action (hyperactivity, aggressive, irritable, anxious, withdrawn, distressed, passive/aggressive
Other:
Home Environment:
Often cooks own meals or has another sibling who does
Moves frequently
Often spends the night away from home (primary residence)
Loss of income
Family crisis
Other:
To be completed by counseling personnel
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