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: ______

Attendance

⁭ 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

⁭ Impulsive

⁭ 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

⁭Tremors

⁭ 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)

Affect

⁭ Anxious

⁭ Frequent crying

⁭ Depressive symptoms

⁭ Overly pessimistic

⁭ Reports nightmares/ night terrors

⁭ Irrational fears

⁭ Disoriented/ confused

⁭ Dramatic mood swings

⁭ Unrealistic goals/ thinking

⁭ Manipulative

⁭ Withdrawn/ socially isolated

⁭ Difficulty with personal boundaries

⁭ Impaired judgment

⁭ Defensive

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) ______

______