Professional School Counselor Referral Process Guide Page 20
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28Missouri Comprehensive Guidance and Counseling Programs: Responsive Services Component
Referral Process Module
Page 20 of 28
Student Behavior Data Collection Form
STUDENT______________________________TEACHER_____________________________DATE___________
Teachers: please indicate areas of concern in the left hand
PSC: use columns on right side.
column.
Performance Indicators:
(+) = Excellent (/) = Satisfactory (-) = Area of Concern
Teacher
Observed Behaviors
Professional School Counselor rating
Concerns
(mark with
X)
Academic Development
Follows directions
Listens attentively
Stays on task
Compliance with teacher requests
Follows rules
Manages personal and school property (e.g., prepared, organized)
Works neatly and carefully
Participates in discussion and activities (e.g., motivation, lack of
participation)
Completes and returns homework
Personal and Social Development
Cooperates with others
Shows respect for others
Allows others to work undisturbed
Accepts responsibility for own misbehavior (e.g., provoking fights,
bullying, fighting, defiant, anger, stealing)
Emotional Issues (e.g., perfectionism, anxiety anger, depression,
suicide, aggression, withdrawn, low self-esteem)
Career Development
Awareness of the World of Work
Self-Appraisal
Decision Making
Goal Setting
Add Other Concerns:
External Issues (e.g., divorce, death, abuse, socio-economic,
incarceration, military deployment)
Other
School Record Data (To be completed by PSC)
Attendance: # of days absent
Attendance: # of days tardy
Discipline: # of referrals
Grades
School nurse visits
Test Scores
(Adapted from Columbia Public Schools. Modify this template as necessary to accommodate local reporting
periods and assessment/data collection processes and procedures.)
Missouri Comprehensive Guidance & Counseling Programs:
Linking School Success to Life Success
To ensure that the work of educators participating in this project will be available for the use of schools, the Department of Elementary
and Secondary Education grants permission for the use of this material for non-commercial purposes only.
May 2015
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