J. M. Hill Student Assistant Program Referral Form 

Student’s Name:                                                         Grade:                Date of Referral:


Please take the time to complete this form by checking the appropriate information. In order to develop effective intervention plans, it is crucial that you communicate any OBSERVABLE behaviors that are relevant to this referral. Observable behavior which can be noted through one of the senses (seen, heard, tasted, smelt, or felt), usually described by action words such as touching, walking, saying, or writing. Please place the referral in a sealed envelope and return it to the school counselor.


Please check the behavior(s) you have observed.



­­___Currently has an IEP or Chapter 15

___Failing or near failing grades

___States a disinterest in academics

___Reads below grade level

___Drop in grades

___Decreased or low class participation

___Fails to complete assignments

___Easily distracted or trouble concentrating

___Short attention span

___ Decrease in the quality of work

___ Poor short-term or long-term memory

___ Does not follow teacher instructions


Attendance Concerns

___Frequent requests to leave the room

___Frequent requests to visit the restroom, nurse or guidance

___Often absent from class

Number of times:______________

___Often tardy to class

Number of times:______________

Physical Observations:

___Unsteady on feet

___Unexplained physical injury

___Frequent cold-like symptoms

___Frequently expresses concerns with personal health

___Complains of nausea or headaches

___Appears disoriented

___Noticeable change in weight

___Poor Hygiene



Behavioral Concerns

___Disruptive Classroom Behavior

___Inappropriate sexual verbalization

___Fighting/threats towards others

___Reports self-abuse (i.e. cuts arm, burns, etc.)

___Openly expresses drug use

___Smells of alcohol/marijuana

___Runaway (student reports)

___ Changes in extracurricular activities

___Change in friends


___Sudden change in behavior

___Change in appetite/eating habits



Emotional Concerns

___Recent death of friend/family member

___Writing or drawing that reflects death or revenge.

___Often criticizes self or others

___Sudden outburst of anger



Strength and Resiliency Factors

___Able to work independently

___Participates in Extracurricular Activities

___Works well in a group

___Demonstrates desire/commitment to learn

___Can accept redirection/criticism

___Exhibits leadership skills

___Helps Others

___ Is connected to and likes school staff