Student Support Services Team Referral Form

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