Delaware Valley Regional High School

Delaware Valley Regional High School

Delaware Valley Regional High School

Confidential Student Referral to the SAC

A student who exhibits any of the following observable behaviors could have a health problem and benefit from a referral to the Core team. Please check the behaviors this student exhibits that are a cause for concern; circle specific behaviors where appropriate. All responses are confidential. Pleasereturn this formto Heather Eckhardt.

Student Name: ______Grade: _____Date: ______

Teacher Name: ______Subject: ______


Academic Performance

 Drop in grades

 Grades not reflective of ability

 Incomplete/ missing assignments

 Decreased participation in class

 Short attention span/ easily distracted

Sleeps in class

 Threatens to drop out

 Other: ______



 Frequently tardy to class

Frequently absent

 Frequent trips to the lavatory

 Frequent trips to the health office

 Frequent trips to counselor

 Pass restriction in place


Disruptive Behavior

 Defiance of rules/ authority

 Frequent discipline problems

 Blaming/ denying

 Verbally abusive

 Physically aggressive

 Cheating/ lying/ stealing

 Obscene language/ gestures

 Dramatic/ attention-seeking behavior

Hyperactivity/ nervousness


 Inappropriate comments

 Other: ______


Physical Indicators

 Avoids eye contact

 Glassy/ bloodshot eyes

 Dilated or constricted pupils

 Unsteady on feet

 Altered/ slurred speech

Drowsy/ lethargic

Frequent cold-like symptoms


 Frequent vomiting/ complaints of nausea

Paranoia/ nervousness

Poor hygiene/ self-care

Complaints of physical pain

 Unexplained physical injuries

 Rapid weight loss/ gain

Smells of alcohol/ marijuana

 Other: ______

(continued on reverse)


Confidential Referral/ Response Form(continued)




 Frequent crying

 Depressive symptoms

 Overly pessimistic

 Reports nightmares/ night terrors

 Irrational fears

 Disoriented/ confused

 Dramatic mood swings

 Unrealistic goals/ thinking


 Withdrawn/ socially isolated

 Difficulty with personal boundaries

 Impaired judgment



Atypical Behavior

Change in friends/ behavior

Withdrawal fromextracurricular activities

Sudden popularity

Older/ significantly younger social group

Sexual behavior in public

 Frequent use of alcohol/ drug street slang

 Carries large amounts of money

Preoccupation with partying

 Writes about alcohol/drugs

 Frequently talks about alcohol/drug use

 Draws alcohol/drug symbols

 Legal problems/ D.U.I.


I have observed the following specific incidents involving this student: ______



I am concerned about the general mood/ attitude of this student. Here is what concerns me: ______



I have observed the student demonstrate the following strengths/ positive personal qualities: ______



The student appears to have the following supportive resources (e.g. concerned friends family members, community connections) ______