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STAT (Student and Teacher Assistance Team)
Referral Form
Purpose: To document observable and measurable behaviors that are detrimental to the student's educational performance.
Goal: This form will provide thorough data to guide the STAT team in designing interventions leading to measurable
improvement in student education performance.
Directions: Please be as thorough as possible in detailing observed behaviors and interventions already attempted.
Referral Source:
Teacher
Counselor
Administrator
Parent
Other
Your Name:
Student Name:
Male
Gender:
Date:
Female
Student knows this form is requested?
Grade Level:
No
Yes
Student's Advisor:
Based on the student's current performance, what would his/her grade be today?
Quarter grade would be:
Semester grade would be:
Observed Behaviors
Concerns: Please attach samples of student work if applicable.
Academic Achievement:
Attendance:
Is doing satisfactory or better
Regularly attends class
Good work one day, poor the next
Frequently tardy
Decline in work
Frequent absences
Excused
Difficulty completing daily work due to:
Unexcused
Negative peer interactions
Intattention
Frequent requests to leave classroom
Bathroom
Poor Skill Levels In (check each that apply):
Reading
Counselor
Writing
Nurse
Math
Organization Skills:
Keeps an assignment notebook
Frequently loses items
Other
Other
Difficulty following directions due to:
Appearance & Health:
Inappropriate movement
Appears healthy
Intattention
Neglects personal hygiene
Classroom Conduct/Demeanor:
Generally cooperative
Low affect (seldom expresses feelings or emotions
Suspected drug & alcohol use
Extreme dissatisfaction with school
Student talks about drugs/alchohol
Inconsistent behavior
Self-reported--brags about drug/alcohol use
Sleeps in class
Peers talk about drug/alcohol use
Withdrawn from peers, teachers, classwork
Smells of alcohol, marijuana, cigarettes
Attention-seeking behaviors
Glassy, bloodshot eyes
No effort/lack of motivation
Slurred speech
Poor concentration skills
Lacks coordination (staggering or stumbling)
Inattentive
Time disorientation
Short attention span
Lethargic/low stamina
Lack of impulse control
Constant or persistent cough
Seeks instant gratification
Pervasive unhappiness
Overactive
Memory loss
Off-task in the classroom
Mood swings
Negative attitude:
Physical injuries
Towards self
Changes in weight
Towards teacher
Vomiting
Towards school work
Extra-curricular
Towards peers
Regular participation
Argumentative:
Disruptive at practice
Obscene language/gestures
Cuts practice
With peers
Quality of participation declining
Off-task in the classroom
Increasing non-involvement
Defiance of rules/authority
Quit team/squad/club
Disruptive:
Sudden outbursts
Obscene language/gestures
Frequently talks out loud
Lies or cheats
Verbally abuses others
Writes or draws graffiti
Relationships:
Student's close friends are:
Loss of eligibility
Social Behaviors
Appears well-adjusted and happy
Change in peer group (negative)
Avoids peers
Excluded by peers
Defensiveness/blaming/denying
Bullies other students
Paranoid (expresses feeling persecuted or picked on)
Inappropriate responses to situations
Please explain:
Previous Interventions:
Social Behaviors, continued
Spoke with student about concerns
Erratic behavior changes:
Results:
Please explain:
Successful parent contact by email or phone
Frequently seeks adult contact
Seeks advice without specific problem
Dramatic attention seeking behaviors
Family issues:
Results:
Unsuccessful parent contact
Contacted advisory teacher
Speaks angrily of parent
Speaks angrily of siblings
Contacted other teachers about strategies that
might be working for them
Changes in family/custody (divorce/remarriage)
Death of family member
Difficulty dealing with cultural issues
Death of a close friend
Talks about or has run away from home
History of disciplinary referrals/suspensions
Inappropriate sexual behavior
Wrote disciplinary referral
Developed a student academic or behavior contract
Modified work:
Checked assignment notebook
Changed student seat/lab group
Other actions taken to correct the behavior
Student
Assets &
Strengths :
Additional
Comments?
Expected
Outcome of This
Referral :
Print Form
For At-Risk Coordinator :
Grades in all classes
Disciplinary Referrals
Requested anecdotal evidence from teachers
Attendance
Student Status
Submit by Email