STUDENT ASSISTANCE TEAM CHECKLIST (Counselor ONLY)

Your Name          Name of Student        Date     

 

 Your Position                Class          Period            Current Grade%

 

PLEASE CHECK THE APPROPRIATE RESPONSES IN EACH SECTION, AND ADD COMMENTS WHEN NEEDED.

 

ATTENDANCE

ATYPICAL BEHAVIOR

PHYSICAL SYMPTOMS

New Student to district

Frequently changed schools

Repeated visits to counselor

Tardiness

Absent excused

Absent unexcused

 

Change in friends

Older/Younger social group

Expresses openly drug use

Cries

Expresses desire to punish or gain revenge via violence

Seeks constant reassurance

Inappropriate dress

Disliked by peers

Sudden change in behavior

Lying

Difficulty making decisions

Expresses involvement in hate groups

Express fear/anxiety

Loner

Criticizes self/others

Express hopelessness, worthlessness, helplessness

Constantly threatens or harasses

Deteriorating personal appearance

Frequent cold-like symptoms

Unsteady on feet

Possible odor of alcohol

Odor of marijuana

Complaints of nausea or vomiting

Glassy, bloodshot eyes

Skin discoloration

Unexplained physical injuries

Fatigue or listlessness

Abnormal weight loss or gain

Slurred speech

Preoccupied with appearance

Poor hygiene

Self abuse

Disoriented

ACADEMIC PERFORMANCE

 Class Rank

Exceptionality

IEP

Currently working with student

Psychological

Schedule changes this year

Previous retention

Change in grades (year to year)

Standardized test scores

Verbalized disinterest in academic performance

CRISIS INDICATORS

STUDENT STRENGTHS/RESILIENCY FACTORS

 

Has expressed desire to die

Has made suicidal threat, gesture

Suicide note

 

 

Participates in extra curricular activities

Enthusiastic

Leadership ability

Cooperative

 

HOME/SCHOOL/FAMILY INDICATORS

 

 

Runaway

Recent divorce/separation

Job loss of family member

Refusal to go home

Recent death of family member or friend

Under CYS care

Foster placement

Does not live with parents

 

 

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