Initial Referral Form
Utilized for initial referral to the Intervention & Referral Service.
Current Grade Average
Number of class absences
Number of times late to class
Classroom Performance (choose all that apply)
Drop in grades, lower achievement
Decrease in class participation
Does not ask for help when needed
Difficulty staying focused; easily distracted by others
Difficulty with immediate recall
Disorganized with school materials
Gives up easily when frustrated
Prefers to work alone
What percentage of the time has this student failed to complete homework? (include your name with answer- Ex. 50%-Tynon)
What percentage of the time has this student failed to complete in class assignments? (include your name with answer- Ex. 50%-Alban)
Social Skills (choose all that apply)
Lacks positive relationships
Disrespectful toward authority
Disturbs other students during classroom activities
Uses leadership skills inappropriately
Frequently argues with the teacher
Hits and/or pushes other students
Does not easily accept constructive criticism
Teases other students
Makes inappropriate remarks to classmates
Makes inappropriate remarks to adults
Frequently ridiculed by classmates
Withdrawn/Has difficulty in relating to others
Lacks control in unstructured situations
Change in friends
Defiance of classroom rules
Does not take responsibility for inappropriate comments or actions
Sudden outbursts of anger
Obscene language, gestures
Erratic behavior, mood swings
Physical Symptoms (check all that apply)
Smells of smoke, alcohol, or marijuana
Dresses inappropriately based on school policy
Frequently requests to see the nurse
Appears sleepy, lethargic
Frequent physical injuries
Deteriorating personal appearance
Sleeps in class
Frequently complaints of nausea, headaches
Glassy, bloodshot eyes
Note: This checklist is not intended as, nor is it appropriate to use as, a scientific or accurate measurement of developmental assets. Copyright (c) 2002 by Search Institute, 615 First Avenue NE, Suite 125, Minneapolis, MN 55413. 800-888-7828.
May be reproduced for educational, noncommercial use only. This checklist is not intended for use as a survey tool.
What do you see as this student's strengths? (Check all that apply)
Student understands and follows school rules and accepts consequences for inappropriate behavior.
Student's friends model responsible behavior.
Student spends three hours or more each week in lessons or practice in music, theater, or other arts.
Student spends three hours or more each week in school or community sports, clubs, or organizations.
Student wants to do well in school.
Student is actively engaged in learning.
Student regularly completes homework assignments.
Student cares about his/her school.
Student reads for pleasure three or more hours each week.
Student believes it is important to help other people.
Student can stand up for what he/she believes.
Student tells the truth even when it's not easy.
Student can accept and take personal responsibility.
Student is good at planning ahead and making decisions.
Student is good at making and keeping friends.
Student knows and is comfortable with people of different cultural/racial/ethnic backgrounds.
Student can resist negative peer pressure and dangerous situations.
Student tries to resolve conflict nonviolently.
Student believes he/she has control over many things that happen to him/her.
Student feels good about him/herself.
Student believes his/her life has a purpose.
Student is optimistic about his/her future.
Initial Referral: Prior Interventions Checklist
Please indicate what types of interventions you have tried prior to the referral and the results achieved.
Prior Interventions (Check all that apply)
Spoke to student privately after class
Gave student help after class or school
Changed student's seat
Spoke with parent on the telephone
Gave student special work at his/her level
Checked cumulative folder
Held conference with parent in school
Sent home notices regarding behavior or school work
Arranged an independent study program for student
Have given student extra attention
Have set up a contingency management program with student
Have assigned student after-school detention
Have referred student to guidance or administration
Send me a copy of my responses.
Never submit passwords through Google Forms.
This form was created inside of New Hanover Township School.
Terms of Service