START Teacher Survey - (copy) - - (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.

A red asterisk (*) indicates required questions.

  1. Please enter your name (not the name of the student):*

  1. Please consider the observable behaviors demonstrated in your contact with the above student. We understand that there are some areas for which you may have no knowledge. Students are referred for a variety of reasons; do not make assumptions regarding this student. This information is to be kept in the strictest confidence.

    Would you like to speak directly to a member of the Student Assistance Team (SAP) in person instead of completing this form?*
    Yes, please contact me.
    No, I will complete this form.

  1. Class Attendance*
    Frequent EXCUSED absences
    Frequent UNEXCUSED absences
    Frequently late to class
    Frequent visits to nurse
    Frequent visits to restroom
    None of the above

  1. Academic Concerns*
    Drop in grades and lower achievement
    Decrease in class participation
    Failure to complete assignments
    Performing below ability
    Short attention span
    Easily distracted
    Verbalized disinterest in academic performance
    Easily frustrated
    Perfectionist achiever
    Unprepared for class
    Difficulty retaining new or recent information
    None of the above

  1. Student Strengths and Resiliency Factors
    Works independently
    Participates in extra curricular activites
    Works well in a group
    Demonstrates desire to learn
    Displays good logic / reasoning
    Accepts criticism
    Considerate of others
    Good communication skills
    Recognizes and respects boundaries
    Establishes relationships with staff
    None of the above

  1. Disruptive Behavior*
    Physically aggressive (fighting, pushing, hitting)
    Sudden outbursts of anger
    Verbally abusive of others
    Obscene language and / or gestures
    Attention seeking behavior
    Extremely negative
    Inappropriate dress
    Denies responsibility, or blames others
    Easily influenced by others
    None of the above

  1. Physical Symptoms*
    Deteriorating personal appearance
    Sleeping in class
    Frequent cold-like symptoms
    Unsteady on feet
    Glassy and / or bloodshot eyes
    Slurred speech
    Unexplained frequent physical injuries
    Fatigue or listlessness
    Weight loss or gain
    Body odor
    Repeatedly wears the same clothing
    None of the above

  1. Home / Family Problems*
    Family problems
    Family alcohol / or drug problems
    Suffered recent loss: move, divorce, death, break-up with boyfriend / girlfriend
    Refused or afraid to go home
    Speaks angrily of parents
    Lives with no parent / guardian supervision
    Expresses desire to live elsewhere
    Other stressors (explain in next section)
    None of the above

  1. Explain other Home / Family Stressors not mentioned in previous section (leave blank if none):

  1. Behavior Concerns*
    Changes in friends / peer group
    Sudden change in behavior / mood swings
    Money concerns (carrying to much, or regularly asking others)
    Bullied by others
    Sudden popularity
    Older / younger social groups
    Sexual behavior / verbalization in public
    Unrealistic goals
    Inappropriate responses
    Withdrawn / loner
    Defensive and / or hostile
    Exhibits self-abusive behavior
    Difficulty in relating to peers
    Expresses involvement in the occult
    Expresses hate for certain groups
    Expresses feelings of worthlessness
    Threatens and / or harasses others
    Expresses interest in hate groups
    Journal and drawings of concern (explain in next section):
    None of the above

  1. Please provide more details regarding the concerning journal entries and/or drawings (leave blank if none):

  1. Drug / Alcohol*
    Openly expresses drug / alcohol use
    Frequently talks about chemical use
    Other students and / or teachers report concerns about drug / alcohol use
    Odor of alcohol
    Odor of marijuana
    Odor of cigarettes
    Has drug / alcohol paraphernalia displayed on books, clothing, etc.
    None of the above

  1. Please add any observable behaviors below that you feel will aid the Student Assistance Team including strengths, needs, peer relationships, and/or home concerns: