Teacher Referral Form CONFIDENTIAL
STUDENT NAME:_________________________________GRADE:____________DATE:_____________
TEACHER NAME:__________________________________
PERIOD:_____________________________
This student has been brought
to the attention of the SCIP team. Your
observations are essential to the decision we must make concerning their
possible need for an evaluation. Please
look at this student carefully and relate to us observable behavior and factual
information. You are not being asked
to draw conclusions about the student’s use of drugs or alcohol. Please check the appropriate responses and
return to the SCIP Box as soon as possible.
Remember – the request for
information must be treated confidentially!
ACADEMIC PREFORMANCE
__No academic problems
__Lower grades/achievement
__Academic failure
__Missing work
__Incomplete work
__Declining quality of work
__Lack of motivation/apathy
SCHOOL ATTENDANCE
__No concerns
__Truancy
__Tardiness
__Suspension
__Counselor visits
__Frequent absences
EXTRACURRICULAR
__Increasing noninvolvement
__Loss of eligibility
__Dropped activities
PHYSICAL SYMPTOMS
__No concerns
__Confusion
__Memory problems
__Spacey
__Drowsy in class
__Sleeping in class
__Time disoriented
__Shakiness
__Nervous/hyperactive
__Poor Hygiene
__Physical complaints/injuries
__Self-inflicted injuries
__Glassy, bloodshot eyes
__Slurred speech
__Smelling of alcohol/pot
OBSERVABLE BEHAVIOR
__No concerns
__Change of friends
__Sudden popularity
__Older social group
__Change in clothing/hair
__Problems with peers
__Avoids adult contact
__Withdrawn
__Loner
__Negative attitude
__Loitering
__Uses pay phone (cell)
frequently
__Avoids eye contact
__Evidence of cult/gang
involvement
__Exchanges or carries large
amounts of money
__Sexually suggestive behavior
__Smokes/uses tobacco
__Talks about drinking/being
drunk
__Talks about drug use/parties
*explain below
__Drug related illustrations
__Possession of drugs or
paraphernalia
__Irresponsibility
__Discipline problems
__Defiance of rules/authority
__Blaming/denying/arguing
*explain below
__Defensive
__Cheating/lying
__Attention-getting behavior
__Sudden outbursts
__Verbal abuse/obscene
gestures
__Intimidation of others
__Involvement in thefts or
assaults
__Erratic/changeable behavior
__Constantly in wrong area
__Self-destructive behaviors
__Rarely smiles
__Appears sad
__Depression/crying
ADDITIONAL INFORMATION: Please
document any information you have on the following:
*Family/living situation:__________________________________________________________________
*Peer group (names of
friends):____________________________________________________________
*Significant staff/adults at
school (coach, counselor, student teacher, etc.):___________ _______________
*Relationship problems
(family, friends, boy/girl friend):________________________________________
*Job information:________________________________________________________________________
**Probation/legal problems:_______________________________________________________________
*Please add additional comments or continue your documentation on the
back of this sheet.