Studentís Name: ______________________________________Birth date___/___/___ Grade__________


Parentís Name: _______________________________________Home Phone: ____________


Fatherís Work Phone: _____________________ Place of work: _______________________


Mother Work Phone: ______________________ Place of work: _______________________


Home Address: __________________________ City & Zip Code: ______________________


Referral Date: ________________Person referring (Name): ___________________________



Student Behavior Checklist



  1. 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q       Withdrawn, difficulty in relating to others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


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 _________________




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 studentís 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



Previous Semester Grades

Most current Semester Grade

Describe any Modifications

























Social Studies




























Semester # to date

Previous Semester #

Describe reasons for the following

Office referrals




Days absent




Days tardy





Additional Comments:












________________________________††††††††††††††††††††††††††††††††††††††††††††††† ___________

Signature of person referring student††††††††††††††††††††††††††††††††††††††††††††††††† Todayís Date








ABC Program:


Date this referral received: ________________


Signature of Behavior Assistant: __________________________