Pine Grove Area School District Student Assistance Program Referral Form

Pine Grove Area School District Student Assistance Program Referral Form
Name of student being referred*

First NameLast Name
School Building*
Grade
Grade
Grade
Date of referral*

MonthDayYear
Date
Person making referral

First NameLast Name
Observable Behaviors (check all that apply)*

Academic DeclineDisciplinary ProblemsExcessive AbsencesFrequent Visits to Nurse or Guidance OfficeDecreased Attention SpanDisregard for School AuthorityConsistent Violation of School Policies and RulesExtreme Dislike or Fear of SchoolObservable Expressions of Anger and/or SadnessObservable Inappropriate Behaviors (i.e., excessive talking, inappropriate laughter, poor anger management)Observable behaviors such as conversations about drugs and alcohol or parties where drugs were presentStudent expresses concern about another students use of Drugs and AlcoholSmell similar to alcohol, marijuana or other drugs and inhalants on student or student's belongingsObservable behavior such as overheard conversation about feeling very sad or depressedObserved significant weight gain or weight lossObserving frequent trips to the restroomOther (please describe below)
Additional Comments:
Should be Empty: