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SCIP Teacher Referal Form

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. 

Pius X • 6000 A St. • Lincoln, NE 68510 • 402-488-0931 • Fax: 402-488-1061

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