Sandy Valley Elementary School CARE Team Student Referral Form for 2017-18 School Year
Please fill in the statements below to refer a student to our CARE Team. Your insight will be helpful as we develop the best strategies/interventions to help this student.
Student First Name
Your answer
Student Last Name
Your answer
Grade
Gender
Parent/Guardian Name
Your answer
Zip Code of Student
Your answer
Referral Submitted By
Your answer
Prior Contact Has Been Made With Family Regarding This Referral
Required
Please check AS MANY concerns below that you have pertaining to your referred student. (The number "1" will be the answer to your concern so that the data can be properly populated for your CARE Team members).
Please check any concern(s) that may apply to your student
Academic
Attendance
Behaviors Needing Office Referrals
Family Support Needed
Social or Emotional Concerns
Suicide Ideation
More specific concerns could revolve around possible TRAUMA-RELATED experiences for students. Please check below ANY trauma concerns you may have for your student.
Please check any trauma concern(s) that may apply to your student
Abuse or Neglect
Death of Family Member or Care Giver
Divorce
Domestic Violence
Homeless
In Foster Care System
Incarcerated Relative
Medical Concern
Mental Health and/or Substance Abuse Concern
On Probation
Please provide a short narrative about your over-all concerns for this student/family:
Your answer
RESILIENCY helps students build and use natural strengths to overcome challenges. What RESILIENCY skills do you feel your student may have from the list below?
Please check any resiliency strength(s) that may apply to your student
Creative
Humorous
Independent
Has Initiative
Insightful
Values Morality
Positive Relationships with Others
Thank you for taking the time to send this referral to our CARE Team. Please hit the submit button to complete this process.
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