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Multi-Tiered Systems of Support
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Behavioral Referral Form
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Faust Intermediate School
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*** Complete Blue Shaded Sections Only ***
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BEHAVIOR CHECKLIST (Insert "x" in applicable box)
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Referring Faculty Member:
Easily frustrated
Inappropriate remarks
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Destructive
Scapegoated by others
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Verbally aggressive
Inappropriate reactions
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Physically aggressive
Difficulty accepting responsibility for own actions
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Student's Name:
Lack of motivation
Misinterprets simple communication
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Unable to anticipate consequences
Defiant
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Not accepted by peers
Argumentative
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Easily distracted
Dishonesty
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Absent and/or truant
Negative attitude
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Current Grade:
Teases or provokes others
Does not follow directions
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Reluctant to speak
Difficulty working with peers
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Impulsivity
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Other:
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Date of Referral:
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SOCIAL-EMOTIONAL CHECKLIST (Insert "x" in applicable box)
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Fearful
Stares blankly
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Anxious
Unable/Unwilling to express feelings
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General Narrative Providing
Unhappy
Avoids calling attention to self
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Statement of Concern
Sadness
Argues with peers over minor situations
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(Behavior, Frequency, Time of
Withdrawal/change from peer group
Must have last word
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Day, Antecedent Action,
Appears to dislike school
Tells outlandish stories
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Consequences):
Experiencing sudden popularity
Boundary-breaker
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Suicidal threat (verbal or written)
Negative social interactions with others
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Homicidal threat (verbal or written)
Inappropriate behaviors in school
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Difficulty problem-solving/compromising
(nose-picking, thumb-sucking, self-stimulation)
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Other:
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HEALTH CHECKLIST (Insert "x" in applicable box)
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Unexplained physical injury
Poor body image
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Frequent cold-like symptoms
Preoccupied with food/dieting
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Self-inflicted marks/cuts/burns
Strict dieting and/or eating binges
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Self-inflicted drawing on the body
Vaping
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Glassy, blood shot eyes
Drug use
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Slurred speech
Alcohol use
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Neglects personal appearance/hygiene
Tobacco use
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Pale or flushed coloration
Tired/Falls asleep in class
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Disoriented/loses balance
Difficulty focusing/maintain attention
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Excessive absences
Sexually acting out
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Other:
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"Committed to meeting the academic, behavioral, health, enrichment and social-emotional needs of all students."
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