Teacher Referral- Counselor, I need help with a student
Thank you for taking the time to fill out this form. A School Counselor is available for students, parents, faculty, and staff by appointment. As soon as I receive the form completed, I will be contacting you for more details and set up appointments.
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Email *
Student Name *
Teacher Name *
Please check the items below that are causing the most difficulty.
Loses temper easily
Loses temper easily
Displays anger when receiving a poor grade
Call other students names
Physically fight with students
Destroy things when angry
Goes into “withdrawal” when angry
Is frequently in a bad or angry mood
Has problems which affect his/her anger in school
Dealing with anger crying, whining, and/or pouting
Poor sportsmanship
Want his/her own way in games or group projects
Threatens other students
Sleeping in class
Following directions
Listening
Keeping hands, objects, feet to self
Working and playing safely
Staying on task
Accepting No
Accepting feedback
Paying Attention
Asking Permission
Other
On a scale of 1-10 (0 lowest and 10 highest) How would you rate the present behavior of the student? What is the highest rating the student has reached in your observation? *
Please explain what you have already tried to help with the issue. *
Comments
A copy of your responses will be emailed to the address you provided.
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