Student Assistance Program Referral Form - Northwestern Lehigh High School

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Name of Person Filling Out Referral (Optional) :

Date *

YYYY

Student being referred *

Grade *

9th

10th

11th

12th

Unknown

Referred by: *

Community Member

Teacher/Staff Member

Peer

Parent

Self

Strength(s) and Resiliency Factors(s) *

Is creative

Considerate of others

Strives to achieve his/her best

Able to work independently

Exhibits leadership

Can accept re-direction

Good communication skills

Appears to like and connected to school

Demonstrates good social skills

Other:

Required

Please check the concerning behaviors(s) you have witnessed: *

Decreased or low class participation

Easily distracted or trouble concentrating

Decrease in the quality of work

Steady decline in academic performance

Poor short-term or long-term memory

Does not follow teacher instructions

Change in attendance/tardiness

Frequent requests to leave the room

Frequent request to visit the nurse

Falling asleep in class/trouble staying awake

Changes in extracurricular activities

Low frustration tolerance

Increased irritability

Argues with other students

Cheating

Change in friends

Drastic changes in appearance

Observed talking about drinking alcohol or using controlled substances

Withdrawal from peers

Sudden change in baseline mood/demeanor

Other:

Required

Additional Observable Behaviors

Are there other outside factors that are occurring with the student that you are aware of? *

Recent death/family loss

Recent loss of income/job in household

Homelessness

Agency involvement (Juvenile probation, children and youth, custody)

Food insecurity

Lack of utilities (heat, running water, electric, gas)

Other:

Required

Clear form

Never submit passwords through Google Forms.

This form was created inside of Northwestern Lehigh School District.

Does this form look suspicious? Report

Forms