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:

Mrs. Shonka – Rm 100

Mrs. Barnes – Rm #275 (located in library) Mrs. Wilkins – Guidance Office

Mrs. Buckley – Library Mr. Wahlen – Guidance Office

Miss Lieb – Ministry Office (near 262)

*Please place completed form in the locked SCIP box in the Guidance office or return via mail to:

Amy Shonka

Pius X SCIP Coordinator

Pius X High School

6000 A Street

Lincoln, NE 68510