Alamance Burlington Schools
Student Support Services Team Referral Form
2014-2015
INSTRUCTIONS: Please print and complete this form for students who appear to be at-risk of school failure or out-of-home placement due to physical, social, legal, emotional, and/or developmental reasons. Send this form to your Student Services Team:
Date of Referral: ______Student Number: ______
Student Name: ______DOB:___ Grade: _____Gender: ____ Race: ______
Teacher Team: ______
Is there active parent participation? ______
Referring Person: ______Phone(s) ______Email______
Has referring person made contact with parent? ______#____Phone______#___Email______#___Personal Contact
Has the parent/guardian been notified of this referral? Yes_____ No______
Additional Comments:
Check all of the Student’s Strengths
Positive AttitudeHigh Self-expectationsHandles conflict wellHard worker
TrustworthyWorks well independentlyGood sense of humorAthletic
CooperatesWorks well in groupsPride in appearanceCooperates
Respects authorityResponsibleTransitions easilyMotivated
Tries hardFocused/Goal directedHas leadership qualitiesOrganized
Provide supporting documentation: (i.e. Individual student attendance profile, incident report(s), grades, IEP/PEP, PSM/SAT/EC)
PLEASE CHECK THE CONCERNS OR CHARACTERISTICS THAT APPLY TO THIS STUDENT:
1. Check all of your Academic Concerns for this Student
Grades decliningPoor writing skillsDoes not work well independently
DisorganizedPoor reading skillsDoes not work well with others
Slow rate of workPoor math skillsDoes not comprehend directions
Poor MemoryPoor study skillsFailed EOC
Retention of1yearFailed 2+ Subjects/CoursesIncomplete assignments
EOG <3ESL/ELL/LEPExcessive absences
2. Check all of your Behavioral Concerns for this Student
Verbally disruptiveVictim of bullying Attention seekingBullies others
Physically disruptiveDestroys propertyAvoided by peersSteals
Physically aggressiveEasily distractedEasily frustratedWithdrawn
Verbally aggressiveArgumentative/defiantHostile when criticizedSleeps in class
Sexually aggressiveExcessive absencesSkips classCheats/lies
ISS/OSS/Incidents
3. Check all of your Emotional Concerns for this Student
Separation anxietyCompulsiveIncapable of emotional self-regulation
Uses profanityBoastful/BossyConfuses fact with fiction
Mood swingsUncontrolled emotionsAnimistic (sees objects as live/human)
Uncontrollable angerUncontrollable cryingOverconcern of peer acceptance
Uncontrollable arguments Gives up easily
4. Check all of your Personal Concerns for this Student
Nervous/FearfulUncoordinatedOver/under weightParenting
Physical complaints Bloodshot eyesSuspected use of alcoholPregnancy
LethargicEvidence of self-mutilationSuspected use of tobaccoPoor hygiene
Suicidal ideationSuspected victim of abuseSuspected use of drugsAgitated
McKinney-VentoBody odorTardies: AM or PM
Please write additional comments or concerns including any items you checked and would like to specifically address:
For SST/SAT/RTI/504/CFST/MV/Health Educator use only
Date Received: SST/SAT/RTI/504/CFST/MV/Health Educator ______Initials______
Date Reviewed:SST/SAT/RTI/504/CFST/MV/Health Educator ______Initials______
Date Referred:SST/SAT/RTI/504/CFST/MV/Health Educator ______Initials______
8/19/2014