CVHS Student Assistance Program Referral Form
This form is CONFIDENTIAL. All referrals will be discussed in a weekly SAP meeting ASAP. If you have serious concern about a student, please contact the student's guidance counselor immediately (in addition to submitting this form). If the referral concerns attendance, incomplete work/failing grades, or disruptive behavior/classroom misconduct primarily, the student will likely be seen through the BRtII process. Please send all questions regarding the referral to the student's guidance counselor.
Please indicate reason for referral by checking the box next to the appropriate observable behavior.
Decrease in class participation
Drop in grades
Does not follow directions
Easily distracted or preoccupied
Failure to complete assignments
Poor to deteriorating reading skills
Poor to deteriorating writing skills
Poor term memory (day to day)
Poor test scores
Short attention span
CLASS ATTENDANCE DURING PAST MONTH
Frequent visitor to counselor
Pattern of absences (please note below)
Frequent visits to nurse
On absentee list, but not in school
Deteriorating personal appearance
Frequent cold-like symptoms (runny nose, watery eyes, cough)
Glassy, bloodshot eyes
Slurred or slowed speech
Smelling of marijuana, alcohol, or tobacco
Unexplained or frequent injuries
Defiance of rules
Irresponsibility, blaming, denying
Obscene language, gestures
Sudden outbursts of anger
Verbally abusive to others
Change in friends
Defensive (feels picked upon)
Obvious mood swings
Seeking adult advice without a specific problem
Overeating/refusal to eat
Sexual behavior in public
Significantly older/younger friends
Talks freely about drug use
Talks freely about considering suicide
Withdrawn, difficulty relating to others
Please remember to report observable behavior, not opinion.
Please share any Tier 1 interventions you've already taken to address this concern.
(i.e., conference with student, parent contact, email to guidance counselor, contact with other staff members, etc.)
Would you like to speak with a member of the SAP team?
Person making referral:
(May be anonymous)
Relationship to student:
Please check one.
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