Conard High School Student Success Team (S.s.t.) Referral Form printable pdf download

Conard High School Student Success Team (S.s.t.) Referral Form

CONARD HIGH SCHOOL

Student Success Team (S.S.T.) Referral Form

Student’s Name: __________________________ Grade: _____ School Counselor: __________________

Referring Person: ___________________________________________ Date of Referral: ______________

How do you know the student? ______________________________________________________________

Have the parents/guardians been contacted at any point this year related to your concerns about this student?

___Yes ___No If so, when was the contact made? ______________ By whom? _ ____________________

Reason for this referral (Please check all that apply):

___ Academics

___ Work Effort/Motivation

___ Emotional Issues

___ Family Issues

___ Attendance

___ Substance Abuse Concerns

___ Friends/Social Issues ___ Other ___________

List the four most serious behaviors of concern and the frequency that you have observed in this

student. Be specific. (Ex. does not complete 90% of hw assignments, gets physical when angry, cries in

school at least 3x/wk, etc.)

1. ______________________________________________________________________________________

2. ______________________________________________________________________________________

3. ______________________________________________________________________________________

4. ______________________________________________________________________________________

List the top four strengths that you have observed in this student (Ex. artistic, athletic, great writer, etc.)

1. ______________________________________________________________________________________

2. ______________________________________________________________________________________

3. ______________________________________________________________________________________

4. ______________________________________________________________________________________

Please list any instructional strategies or interventions that have been tried: (Ex. Parent contact, support

staff consultation, emotional supports, classroom interventions- organization or content related.)

*Return form to student’s school counselor.

Conard High School Student Success Team (S.s.t.) Referral Form