Pine Grove Area School District Student Assistance Program Referral Form
Name of student being referred
*
First Name
Last Name
School Building
*
Please Select
Elementary School
Middle School
High School
Grade
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
Grade
Please Select
5th Grade
6th Grade
7th Grade
8th Grade
Grade
Please Select
9th Grade
10th Grade
11th Grade
12th Grade
Date of referral
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Person making referral
First Name
Last Name
Observable Behaviors (check all that apply)
*
Academic Decline
Disciplinary Problems
Excessive Absences
Frequent Visits to Nurse or Guidance Office
Decreased Attention Span
Disregard for School Authority
Consistent Violation of School Policies and Rules
Extreme Dislike or Fear of School
Observable Expressions of Anger and/or Sadness
Observable 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 present
Student expresses concern about another students use of Drugs and Alcohol
Smell similar to alcohol, marijuana or other drugs and inhalants on student or student's belongings
Observable behavior such as overheard conversation about feeling very sad or depressed
Observed significant weight gain or weight loss
Observing frequent trips to the restroom
Other (please describe below)
Additional Comments:
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