• 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