REFERRAL
FORM
BERESFORD
ELEMENTARY ABC BEHAVIOR PROGRAM
Student’s Name:
______________________________________Birth date___/___/___ Grade__________
Parent’s Name:
_______________________________________Home Phone: ____________
Father’s Work Phone: _____________________ Place of work:
_______________________
Mother Work Phone: ______________________ Place of work:
_______________________
Home Address: __________________________ City & Zip
Code: ______________________
Referral Date: ________________Person referring (Name):
___________________________
Student Behavior Checklist
- Reason for referral:
Must be for school-based issues.
2. Observed behaviors: Must be
specific and descriptive.
3. Areas of concern (check all
that apply)
Social Skills
q
Appears to be a loner
q
Lack of peer relationships
q
Disrespectful of authority
q
Disturbs other students
q
Slow in making friends
q
Is stubborn
q
Negative leader
q
Argues with teacher
q
Has no friends
q
Hits and/or pushes other students
q
Teases other students
q
Angered by any criticism
q
Lack of self-confidence
q
Resents authority (attitude)
q
Theft/vandalism
q
Inappropriate language
q
Has to be center of attention
q
Frequent ridicule from classmates
q
Appears unhappy/sad
q
Appears lonely
q
Lacks control in unstructured situations
q
Change in friends
q
Sexual behavior in public
q
Withdrawn, difficulty in relating to others
q
Talks freely about drugs
q
Other inappropriate social behavior (explain__________)
Disruptive Behavior
q
Defiance of rules
q
Fighting
q
Cheating
q
Sudden outbursts of anger; verbally abusive to others
q
Obscene language, gestures
q
Noisy, boisterous
q
Crying
q
Highly active
q
Erratic behavior/mood swings
q
Irresponsibility, blaming, denying
*If you have checked any item in the above area, please
attach another piece of paper and explain in detail.
Physical Symptoms
q
Underweight
q
Overweight
q
Smell of smoke, alcohol, marijuana
q
Coming to school inappropriate dressed
q
Tense, seems on edge
q
Slurred speech
q
Appears sleepy, lethargic
q
Frequent physical injuries
q
Deteriorating personal appearance
q
Sleeping in class
q
Glassy, bloodshot eyes
q
Poor hygiene
q
Frequent requests to see the nurse
4.
Background
information (if known, Please do not ask child or family directly)
q
Attendance problems
q
Latch-key child
q
Involvement with other community agencies
q
Death in immediate family
q
Divorce or separation
q
Unemployment
q
Single parent household
q
Siblings _____________________
q
Lives with someone other than parent
q
Known medical problems
q
Child discusses concern regarding drug and alcohol use
in the home
q
Takes medication ____________
q
Previously involved with counseling
q
Currently involved with counseling
5. Related Services
School Based:
q
School Counselor
q
Title Services
q
Reading recovery
q
IEP
q
Resource Room
q
Speech and Language
q
Gifted/Talented Program
q
Others Specialist ______________
Community/Agency Based:
outside of
school
q
List if known ______________
6. List 1-3 positive qualities you see in
this student:
These behaviors typically occur
Location:
q
In Class
q
Hallway
q
Cafeteria
q
Bus
q
Gym
q
Restroom
q
Playground
q
Library
q
Other ___________________
q
Before school
q
Early-morning
q
Mid-morning
q
Lunch
q
Early-afternoon
q
Mid-afternoon
q
Other _________________
Class:
q
All classes
q
Transition between classes
q
Unstructured activity
q
Specific class/activity _______________
Other comments:
________________________________________________________________________
________________________________________________________________________________
7. Describe parent
participation:
8. Prior Interventions
(Please describe what types of
interventions you have tried prior to referral)
1.
Spoke to student privately after class _______
Explained class rules and expectations _______
Explained concerns _______
2. Gave student help after
class/school _______
3. Changed student’s seat _______
4. Spoke with parent on the
telephone _______
5. Held conference with parent in
school _______
6. Gave student special work at
his/her level _______
7. Sent home notices regarding
behavior/school work _______
8. Have given student extra
attention _______
9. Set up management program with
student _______
10. Have referred to guidance _______
11. Have referred student to
administration _______
12. Provided special encouragement
or reinforcement _______
13. Assign student to special
responsibilities in the classroom_______
14. Provide routine schedules of
feedback to the student _______
15. Established clear classroom
rules that are posted _______
16. Modified or varied assignments _______
17. Provided a mentor or tutor _______
18. Used a study carrel or special
area to work _______
19. Others
________________________________
9. Academic Status
|
Class
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Previous
Semester Grades
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Most current
Semester Grade
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Describe any
Modifications
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Spelling
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Writing
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Language
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Reading
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Math
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Science
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Social Studies
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Computer
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PE
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Music
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Spanish
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Art
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Semester # to date
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Previous Semester #
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Describe reasons for the following
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Office referrals
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Days absent
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Days tardy
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Additional Comments:
________________________________ ___________
Signature of person referring student Today’s
Date
ABC Program:
Date this referral received: ________________
Signature of Behavior Assistant:
__________________________