REFERRAL FORM

BERESFORD ELEMENTARY ABC BEHAVIOR PROGRAM

 

 

 

 

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q       Withdrawn, difficulty in relating to others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

Location:


q       In Class

q       Hallway

q       Cafeteria

q       Bus

q       Gym

q       Restroom

q       Playground

q       Library

q       Other ___________________

 


 

 

Time:


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 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

 

Class

Previous Semester Grades

Most current Semester Grade

Describe any Modifications

Spelling

 

 

 

Writing

 

 

 

Language

 

 

 

Reading

 

 

 

Math

 

 

 

Science

 

 

 

Social Studies

 

 

 

Computer

 

 

 

PE

 

 

 

Music

 

 

 

Spanish

 

 

 

Art

 

 

 

 

 

 

 

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: __________________________