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. Attendance observations and interventions
    This student's attendance is monitored due to a history of concerns
    1st 10% letter
    2nd 10% letter
    Physician's excuse note only
    SAIP process
    Truancy court
    Social Worker is actively involved

  1. If you have communicated with outside agencies working with this student describe the nature of the contact (i.e. probation, C&Y, physician, psychologist).

  1. This student OR parent has been in contact for the following reason(s):

    Victim of bullying or harassment
    Support with home or family problem
    Financial concerns
    Social or peer issues
    Concern with educational professional or course
    School bus or transportation concern
    Social media issues
    Suspicion or evidence of substance involvement
    Legal issues
    Other (explain in details)
    NONE of the above

  1. Has this student ever had an out of school suspension?

  1. Discipline related referrals
    Assault or Fighting
    Terroristic threats
    Dress code
    Cheating or plagiarism
    Possession and /or use of tobacco or vape
    Possession and /or use of alcohol
    Possession and /or use of other drug or paraphernalia
    Posession of weapon
    Misuse of electronic device, school computer, or internet
    Bullying or Harassment
    Class cut(s)
    Out of bounds
    Misbehavior in cafeteria
    None of the above

  1. Types of Interventions:
    Student conference
    Parent contact or conference
    Team meeting
    Referral for resource based services: social worker, counselor, child study, nurse, 504, spec education, SAP (explain in details)
    Peer mediation
    Crisis referral
    Loss of co-curricular eligibility
    Have conducted search of student, vehicle, or belongings.
    None of the above
    Other (explain in details)

  1. General observations observed or reported:
    Inappropriate language or gestures
    Verbally abusive or threatens others
    Sent out of class by teacher to house office for specific behavior
    Sleeps in class
    Sudden outburst of anger
    Disturbs or distracts other students
    Non-compliance of classroom rules
    Denies responsibility or blames others
    Frequent or patterned visits to the restroom
    Appears or suspicion to be under the influence of substance
    Possession of large amounts of money or in debt
    Academically at risk
    Expresses desire to seek revenge or retaliate
    None of the above

  1. In the space below, please elaborate on anything from above or provide additional information you deem appropriate to the referral:

CB South
Warrington, PA