STUDENT ASSISTANCE TEAM CHECKLIST

Your Name         Name of Student       Date    

 

Class         Period           Current Grade%

 

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

 

ACADEMIC PERFORMANCE

ATYPICAL BEHAVIOR

PHYSICAL SYMPTOMS

Drop in Grades, lower achievement

Decrease in class participation

Poor reading/writing/computation skills

Failure to complete assignments

Unprepared for class

Scores poorly on tests

Lack of interest

Short attention span

Easily distracted

Poor short-term memory

Easily frustrated

Cheating

 

Mood Swings

Disoriented

Inappropriate responses/comments

Depression

Defensive

Withdrawn

Expresses desire to die

Leaves clues with death themes to be found

Expresses hopelessness/helplessness

Sighs or cries often

Has given away prized possessions

Verbal suicide threat

Suicide gesture or attempt

Dramatic upswing in mood after depression

Talks freely about drug/alcohol use

Extreme aggression

Extreme impulsiveness and immaturity

Self-mutilation - marks or draws on body

Unwilling to change for PE

Lying

 

 

Deteriorating personal appearance

Sleeping in class

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

CLASS ATTENDANCE

STUDENT STRENGTHS/RESILIENCY FACTORS

EXTRA CURRICULAR ACTIVITIES

Tardy for class

On absentee list but in school

Cutting class

Frequent visits to nurse

Frequent visits to guidance.

Seen in hallways during class

 

 

Participates in extra curricular activities

Enthusiastic

Leadership ability

Cooperative

Loss of eligibility

Missed practice without reason

Dropped out of activity

DISRUPTIVE BEHAVIOR

 

PEERS

Irresponsibility, blaming, denying

Fighting

Outbursts of anger

Verbally abusive

Obscene language

Destructive behavior

Attention getting behavior

Hyperactivity, nervousness

Hits, pushes others

Repeated violation of rules

 

 

Change in friends

Older social group

Younger social group

Exclusion by peers

Constantly associates with adults

Avoids peers

Sudden popularity

Displays of inappropriate affection

Close relationships broken

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