The following student has been referred to the Collaborative/Instructional Team. Please take a few moments to complete this form and return to the individual listed below. Student: _________________________________ WVEIS #: ___________________________ Teacher: _________________________________ Grade: ______ Period/Time: ____________ Please return to: __________________________
by: _________________________________
Date of request: _______________ Please check all that apply: STRENGTHS Social skills with peers Motivated Engages adults Sense of humor Leader Other
BEHAVIOR Generally cooperative Inconsistent behavior Withdrawn, loner Class clown Sleeps in class Argumentative Mood swings Classroom disruption Physically aggressive
ATTENDANCE Regularly attends classes Frequent absences Frequent tardies Frequent ISS Frequent OSS Frequent requests to go to the restroom or nurse
ACADEMIC Often frustrated Decreased motivation High Achiever Sudden decline in grades No effort Academic failures Increased apathy Organization concerns
APPEARANCE / HEALTH Appears healthy Changes in weight Neglects personal appearance Chemical / Smoke odors Lethargic Seems to lack stamina
SOCIAL BEHAVIOR Appears well-adjusted / happy Change in friends / negative Sudden popularity Avoids peers Seldom expresses feelings Defensive with adults Family problems known Acts as a bully Anxious / Fearful Frequently talks about drugs and or alcohol Usually has large amounts of cash Mentions sibling problems Depression Associated with drug / alcohol use Paranoid (feels picked on) Suffered recent family loss ( death, divorce, moved)