Student Assistance Team - Request for Assistance

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Use this form to request SAT review/request assistance in meeting a student's unique behavioral, academic, mental health related or family needs.

Email *

Date: *

YYYY

Student LAST name: *

Student FIRST name: *

YOUR first and last name *

Relationship to student *

Parent/Caregiver/Guardian

Teacher/Staff Member

Other:

Reason for Referral (Check all that apply) *

Academic concerns (lack of performance, organization, goal setting, persisting through frustration, growth mindset, time management)

Emotional Regulation (identifying, expressing, and coping with emotions)

Social Skill concerns (cooperation, social cues, communication, making and keeping friends, conversation skills)

Behavioral concerns (fight, flight, or freeze behaviors)

Family conflict or change (divorce, family member moving away, family member in prison/jail, etc)

Home life concerns (difficulty having basic needs met)

Grief (death of a pet or family member)

Attendance Concerns

Other:

Required

*Staff only* Please check all Tier 1 Supports that are in place

Classroom Procedures and Routines are posted and routinely reviewed (Pax Vision).

Classroom routines are predictable and explicitly taught and practiced

Classroom environment is student-friendly. All students can be seen at all times, there are paths for easy student and teacher movement and materials are organized and accessible

Students are actively supervised - teacher is scanning, moving and interacting

*Students have varied and frequent opportunities to respond including individual/small group questioning, choral responding and nonverbal responses (Pax sticks are utilized)

*Behavior specific praise given at ratio of 4 positive to 1 negative

*Responses to behavior are calm, brief and respectful

Other:

Define the Problem (Academic) - Describe the academic concerns

Define the Problem (Social Emotional/Behavior) - What is the problem behavior? What settings and situations is the behavior most likely to occur:

Define the Problem (Other) - Describe the Family/Homelife/other concerns

What have you tried/used? How has it worked? *

What are some of the child's strengths and interests? (What do they excel at? What do they like to do?) *

Your preferred method of contact *

Phone call

Text message

Your daytime phone number *

I am interested in these other sources of support:

Referral to counseling in the community

Information about grief/loss support groups in the community

Parenting classes or workshops

Online resources and information I can use to help my child

Other:

Additional comments:

By typing my name below, I understand that information shared on this referral form will be shared with members of the Student Assistance Team and the caregiver (as appropriate). Depending on the nature of the concerns, information may be shared with others on a need-to-know basis in accordance with Family Educational Rights and Privacy Act (FERPA) regulations.

A copy of your responses will be emailed to the address you provided.

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