START Counselor Survey (Student Name in Email)

Concern for the following student has been brought to the attention of the Student Assistance Team. Please note your observations on this form. This information will be used to help the student and his or her family to clarify the concern and determine an appropriate action.
Name: 


A red asterisk (*) indicates required questions.

  1. Your identity will not be seen on the collected data print out, or disclosed to the parent/student. Would you prefer a member of the Student Assistance Team to contact you instead of completing this form?*
    Yes, please contact me.
    No, I will complete this form.


  1. Number of ACADEMIC Contacts:


  1. Number of PERSONAL Contacts:


  1. Number of CONCERNING BEHAVIOR Contacts:


  1. Number of PARENT Contacts:


  1. Number of OTHER Contacts, or any comments:



  1. Please check all that you have observed about this student.

    Academic Performance
    Has a IEP/504 Plan
    Regularly working with this student
    Psychological/Psychoeducational on file (list year/grade in details section)
    Previously retained (list grade retained in details section)
    Academic performance is not commensurate with standard test scores
    Verbalized disinterest in academic performance
    Does not take advantage of extra assistance offered/available
    Student is ESL (English as a second language)


  1. Please explain any details from the Academic Performance section:


  1. Crisis Indicators
    Crisis intervention for suicide
    Has expressed desire to die
    Has made suicidal threat, gesture
    Has experienced a recent death of a family member or friend
    Has experienced a recent major illness of family member or close friend
    Has expressed a desire to join someone who has died
    Exibits self-abusive behavior
    Other stressors (explain in details)


  1. Please explain any details from the Crisis Indicators section:


  1. Home/School/Family Indicators
    Runaway
    Recent divorce/separation
    Absence of caregiver (list details in section below)
    Job loss of family member
    Refusal to go home
    Hangs around school for no aparent reason
    Other family stressors (list details in section below)


  1. Please explain any details from the Home/School/Family section:


  1. Atypical Behavior
    Change in friends
    OLDER social group
    YOUNGER social group
    Openly expresses alcohol and other drug usage
    Cries
    Expresses desire to punish or gain revenge via harmful or deadly means
    Wears drug/alcohol related clothing
    Inappropriate or revealing clothing
    Seeks constant reassurance
    Disliked by peers
    Dramatic/sudden change of behavior
    Expresses anger towards parent(s) or authority figure(s)
    Lying
    Difficulty making decisions
    Expresses involvement in the occult
    Expresses involvement in hate groups
    Expresses fear, or anxiety (explain in details section)
    Loner/withdrawn
    Criticizes self or others
    Inappropriate language
    Engages in dangerous behaviors
    Expresses hopelessness, worthlessness, or helplessness
    Constantly threatens or harasses
    Inappropriate sexual verbalization and /or behaviors
    Ethnic intimidation
    Appears depressed
    Experiences mood swings
    Hyper-active
    Journal / drawings are concerning (explain in details section)


  1. Please explain any details from the Atypical Behavior section:


  1. Strengths and Resiliency
    Participates in extra curricular activities
    Works well in a group
    Demonstrates desire / commitment to learn
    Displays good logic / reasoning & decision making
    Exhibits leadership skills
    Can accept re-direction / criticism
    Considerate of others
    Good communication skills
    Cooperative
    Possesses good interpersonal skills
    Displays positive values (responsibility, honesty, equality, caring)
    Recognizes and respects appropriate boundaries & expectations
    Demonstrates constructive use of time
    Helps others
    Is connected to, and likes school staff
    Strives to achieve his/her best


  1. Types of Interventions Used:


  1. In the space below, please provide any information concerning your contacts with outside agencies and the progress observed (only possible if a release of information form has been signed).


  1. Have you put the following in the case manager's mailbox:
    - Attendance records
    - Past 2 years final report card
    - Most recent report card
    - Transcripts
    - Standardized test scores
    - Most recent IPR*
    Yes
    No





Mrs. Graham
Science Teacher
Central Bucks HS South
Doylestown, PA