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Elementary SAP Referral Form
Clarion Area Elementary School
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Email
*
Your email
Your Name
*
Your answer
Student First & Last Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
Academic Performance
*
Lack of participation
Easily distracted
Short attention span
Lower achievement
Does not complete assignments
Other:
Required
Health & Physical
*
Poor hygeine
Frequent illnesses
Unexplained/frequent physical injuries/bruises
Sleeping in class
Odor of smoke or other substance
Abnormal weight loss/gain
Other:
Required
School Attendance
*
Frequent tardies
Frequent absence
Other:
Required
Social/Emotional & Behavioral
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Attention seeking
Defiance of school rules
Easily angry
Often sad, frequent crying
Easily frustrated
Lack of self control
Inappropriate language
Fighting/arguing, physical/verbal
Lying
Plays alone often
Exhibits self-injurous behaviors
Friendship issues
Talks, writes, draws about drugs & alcohol
Talks, writes, draws about violence
Lethargic
Other:
Required
Family Concerns
*
Divorce/separation
Domestic violence
Being raised by someone other than a biological parent (grandparent, aunt, uncle, foster, etc)
Parent deployment
Lack of resosurces (food, utilities, housing)
Drug & alcohol
Other:
Required
Student Strengths
*
Optimistic
A good student
Extra-curricular interests
Positive family relationships
Positive friendships
Other:
Required
Additional Comments
Your answer
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