EYMS SNAP Online Referral Form
Thank you for taking the time to express your care and concern about the students here at Eastern York Middle School.
Please use the form below to provide information about the student of concern. Please don't forget to click the submit button to ensure that we receive your responses. Unless you would like to speak with a member of the SNAP team, your identity will remain anonymous.
Student's grade level
Is that child in immediate danger?
Please indicated the reason(s) for referral by checking any and all of the appropriate observable behaviors
Decrease in class participation
Drop in grades
Does not follow directions
Failure to complete assignments
Deteriorating reading skills
Deteriorating writing skills
Poor short-term memory
Poor test scores
Short attention span
Pattern to absences noted
Frequent visits to the school nurse
Frequent visits to the guidance counselor
Deteriorating personal appearance
Frequent cold-like symptoms (Runny nose, watery eyes, cough, etc.)
Glassy, bloodshot eyes
Slurred or slowed speech
Smelling of tobacco, alcohol, and/or Marijuana
Unexplained, 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
Refusal to eat
Sexual behavior in public
Significantly older/younger friends
Talks freely about drug use
(Please remember to report ONLY observable behaviors, not opinions)
Would you like to speak with a member of the SNAP Team?
What is your name? (You only need to enter your name if you would like to speak to a SAP Team Member. Your name and your referral will be kept confidential.)
(Last Name, First Name) Example: Jones, Sally
What is your relation to the student being referred?
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This form was created inside of Eastern York School District.