COUNSELOR Survey - (copy)

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. Please contact the case manager directly if you have any concerns about confidentiality of sensitive information.



A red asterisk (*) indicates required questions.


  1. Please enter YOUR NAME:*


  1. Please check the nature of your contact(s)with student to date:*
    Program Planning
    School counseling / personal issues
    Academic check-in(s)
    Monitor academic performance closely
    Parent Contact
    Titan Forum Visits
    Post-Secondary Planning
    Counsel small group in which this student participates
    Peer mediation
    Work with this student on an extracurricular activity
    Behavioral concern contact
    Regularly working with this student
    None of the above


  1. OTHER Contact with this student or comments from above:


  1. Academic information, observations or concerns: *
    Psychological/Psychoeducational on file (list year/grade in details section)
    Has a current IEP or 504
    Previously had an IEP or 504
    Student was previously in the ESL program
    Student was new to CBSD between grades 9-12
    Academic performance is not commensurate with standard test scores
    Has failed a class between grades 9-12
    Previously retained or not on track to graduate with 9th grade cohort
    Verbalized disinterest in academic performance
    Does not take advantage of extra assistance offered/available
    None of the above


  1. Please explain any details from Academic Observations:


  1. Crisis Indicators*
    Crisis intervention for suicide
    Has expressed desire to die
    Has made suicidal threat or 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)
    None of the above


  1. Please explain any details from Crisis Indicators:


  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)
    None of the above


  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
    Threatens or harasses
    Inappropriate sexual verbalization and /or behaviors
    Ethnic intimidation
    Appears depressed
    Experiences mood swings
    Hyperactive
    Journal / drawings are concerning (explain in details section)
    None of the above


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


  1. Strengths and Resiliency Factors*
    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 / constructive 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
    None of the above


  1. Types of interventions or resources used in school or community:


  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
    - Most recent report card if not posted on transcript
    - Transcript

    *
    Yes
    No





CB South
Warrington, PA