1. INTERVENTION SPECIALIST REFERRAL FORM
    1. Student: _______________________ Grade: ____ Student # ___________
    2. Referred By: _________________________ Date: __________________


INTERVENTION SPECIALIST REFERRAL FORM

 


If you are concerned that a student may be using drugs and/or alcohol, 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, Lyn Lauzon, 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.


 





Student: _______________________ Grade: ____ Student # ___________

 





Referred By: _________________________  Date: __________________

 
1. Possible Alcohol/Other 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)
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 other concerns that are not listed above or do not appear to fit, please list here:______________________________________________________________________________________________________________________________________________________________________________________________________

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