Level of Urgency:
A. Academic Performance:
Decline in quality of work
Decline in grade earned
Work not handed in
Failing in this subject
Capable of better work
Defiance; breaking rules
Frequently needs discipline
Defiance of authority
Obscene language, gestures
Sudden outbursts of temper
In-School absenteeism (skipping)
Tardiness to class
Frequent visits to sick room
Frequent signing out of school early
Frequent visits to lavatory
Frequent visits to counselor
Lack of concentration
Lack of motivation
Sleeping in class
Erratic behavior day-to-day
Change in friends and/or peer group
Sudden, unexplained popularity
Seeks constant adult contact
Seeks adult advice without a specific problem
Apparent changes in personal values
Depression, low affect
Withdrawal: a loner; separateness from others
Compulsive over achievement;
preoccupied with school success
Change in personal appearance
Possible Alcohol, Tobacco and Other Drug Specific
If you have discussed any of these concerns with this
student, please comment.
Have the parents been contacted?
-- If Yes, what was their response?
What other actions have you already taken?
What actions do you contemplate taking?