SAT Referral Form

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SAT Referral Form

Background Information

Date: *

Teachers Name *

Student Name: *

Grade Level *

1st

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

Subject(s)/ Course(s): *

Current Grade Average *

% of homework student has failed to complete? *

% of in-class assignments student has failed to complete *

# of class absences *

# of times late for class (tardies) *

Academic, Behavioral, & Health Information

Classroom Performance *

Please check all that apply

Attendance Problem

Tardiness Problem

Drop in grades, lower achievement

Decrease in class participation

Does not ask for help when needed

Has failed to complete his or her homework

Difficulty staying focused, easily distracted by others

Difficulty with immediate recall

Disorganized with school materials

Gives up easily when frustrated

Prefers to work alone

Fails to complete in class assignments

None

Required

Social Skills *

Please check all that apply

Lacks positive peer 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 classmate, adults

Lacks self-confidence

Frequently ridiculed by classmates

Appears unhappy/ sad

Withdrawn, has difficulty in relating to others

Lacks control in unstructured situations

Change in friends

Disruptive behavior

Defiance of classroom rules

Does not take responsibility for innapropriate comments or actions

Cheating

Sudden outbursts of anger

Obscene language, gestures

Noisy, boisterous

Erratic behavior, mood swings

None

Required

Physical Symptoms *

Please check all that apply

Smells of smoke, alcohol, or marijuana

Dresses inappropriately based on school policy

Slurred speech

Frequently requests to see the nurse

Appears sleepy, lethargic

Frequent physical injuries

Deteriorating personal appearance

Sleeps in class

Frequent complaints of nausea, headaches

Glassy, bloodshot eyes

Poor hygiene

None

Required

Student's Strengths & Developmental Assets

Student's Strengths *

Please check all strengths/ assets you believe this student has

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, theatre, 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.

Students 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, and 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.

Required

External Developmental Assets *

Select all the developmental assets this student has.

Family Support (Family life provides high levels of love and support.)

Positive family communication (Young person and parent/s communicate positiively, and young person is willing to seek advice and counsel from parent/s.)

Other adult relationships (Young person receives support from three or more non-parent adults.)

Caring Neighborhood (Young person experiences caring neighbors.)

Caring school climate (School provides a caring, encouraging, environment.)

Parent involvement in schooling (Parent/s are actively involved in helping young person succeed in school.)

Community values youth (Young person experiences caring neighbors.)

Youth as resources (Young people are given useful roles in community.)

Service to others (Young person serves in the community one hour or more per week.)

Safety (Young person feels safe at home, at school, and in the neighborhood.)

Family Boundaries (Family has clear rules and consequences, and monitors the young person's whereabouts.)

School Boundaries (School provides clear rules and consequences.)

Neighborhood boundaries (Neighbors take responsibility for monitoring young people's behavior.)

Adult role models (Parent/s and other adults model responsible, positive behavior.)

Positiive peer influence (Young person's best friends model positiive, responsible behavior.)

High Expectations (Both parent/s and teachers encourage the young person to do well.)

Creative Activities (Young person spends three or more hours per week in lessons or practice in music, theather, or other arts.)

Youth Programs (Young person spends three or more hours per week in sports, clubs, or organizations at school and/ or in the community.)

Religious community (Young person spends one or more hours per week in activities in a religious institution.)

Time at home (Young person is out with friends two or fewer nights per week.)

Required

Internal Developmental Assets *

Select all of the internal assets this student has?

Achievement motivation (Young person is motivated to do well in school.)

School engagement (Young person is actively engaged in learning.)

Homework (Young person reports doing at least one hour of homework every school day.)

Bonding to school (Young person cares about his/ her school.)

Reading for pleasure (Young person reads for pleasure three or more times per week.)

Caring (Young person places high value on helping other people.)

Equality and social justice (Young person places high value on promoting equality and reducing hunger and poverty.)

Integrity (Young person acts on convictions and stands up for his/her beliefs.)

Honesty (Young person tells the truth even when not easy.)

Responsibility (Young person accepts and takes personal responsibility.)

Restraint (Young person believes it is important not to be sexually active or to use alcohol or other drugs.)

Planning and decision-making (Young person knows how to plan ahead and make choices.)

Interpersonal competence (Young person has empathy, sensitivity, and friendship skills.)

Cultural competence (Young person has knowledge of and comfort with people of different cultural/ racial/ ethnic backgrounds.)

Resistance skills (Young person can resist negative peer pressure and dangerous situations.)

Peaceful conflict resolution (Young person seeks to resolve conflict nonviolently.)

Personal power (Young person feels he/ she has control over "things that happen to me."

Self-esteem (Young person reports making a high self-esteem.)

Sense of purpose (Young person reports that "my life has a purpose.")

Positive view of personal future (Young person is optimistic about his/ her personal future.)

Required

Prior Interventions Checklist

Indicate what interventions you have tried prior to referral. *

Please check all that you have tried

Spoke to student privately after class.

Gave student help before/ after school.

Changed student's seat.

Spoke with parent/guardian 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 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.

None

Required

Other Interventions Tried *

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