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Student Referral Form

Please fill out the form as completely as possible.  Click "submit" when the form is completed.  If you would like to share your name, it may help us to be able to ask further questions.  However, you can submit this form anonymously if you prefer.

I am concerned about my friend:   who is in the following 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

Often is a victim of bullying by others

Often bullies others

Cries easily

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 wish to share your name, please do so here: 

 

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

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