If you are concerned that a student may be using substances, including vape, please refer to the behaviors listed below. If you have observed any of these behaviors on a repeated basis, a referral to the Intervention Specialist, Mike Keiss, is appropriate. It is also appropriate to refer students who have been affected by drug and/or alcohol use.
Please indicate the behaviors you are concerned about, put this form in an envelope marked “CONFIDENTIAL” and put it in my mailbox or email: mkeiss@everettsd.org
Student: ________________________________ Grade: ______ SID: _______________
Referred By: _______________________________ Date: _______________________
1) Possible Alcohol/Drug Behaviors
a. Talking freely about drug and/or alcohol use; “bragging”
b. Told you they use drugs and/or alcohol.
c. Appears they are using (attitude, overall appearance, smells or odors of substances)
d. Other students report use or concerns
e. Associates with other apparent users
f. How long ago did these behaviors begin? __________________
2) Academic Performance
a. Decline in quality of work
b. Decline in grade earned
c. Incomplete work
d. How long ago did these behaviors begin? __________________
3) Classroom Conduct
a. Frequently needs discipline
b. Sudden outburst of temper
c. Verbally abusive
d. Defiance of authority
e. How long ago did these behaviors begin? __________________
If you have any other concerns that are not listed above or do not appear to fit, please list here: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________