Parent Referral Form CONFIDENTIAL
SCIP
School Community Intervention Program
My
name:_______________________________________________________________
Date:__________________
Phone number where I can be reached:_________________
I
am concerned about ______________________________ ______________________
(Name) (Grade)
I
am concerned because:
Please
check any behaviors you have frequently observed (and add any behaviors you are
concerned about):
_____
Seems depressed a lot
_____ Cries easily
_____ Often victimized
_____ Often victimizes
others
_____ Fighting
_____ Irresponsible –
blames – denies – argues
_____ Doesn’t interact
with friends anymore
_____ Missing school
_____ Extreme negativism
_____ Erratic day to day
behavior
_____ Comments about own
alcohol/drug use
_____ Selling drugs,
exchanges of money
_____ Shows signs of
possible abuse/neglect (please describe)
_____ Smelling of alcohol
or pot
_____
Other (please explain)
If
you have questions, please see a SCIP team member:
*Please
place completed form in the locked SCIP box in the Guidance office or return
via mail to:
Pius X High School
Attn: SCIP Coordinator