STUDENT ASSISTANCE
MODEL
PREVENTION THROUGH
EDUCATION
Lebanon Middle School
Lebanon, Connecticut 06249
INTRODUCTION
We at Lebanon Middle School recognize the value and right of each individual to grow, develop and learn in a safe, drug free environment. Substance abuse and dependency endanger the safety and well being of individuals within the school community and will not be tolerated. At the same time we recognize that drug use and abuse may be indicative of serious underlying problems. We recognize that students often have personal problems such as depression, sexual problems, eating disorders, personal loss, alcoholic parents, child abuse and divorce. We acknowledge that such problems can interfere with school performance. Every effort will be made to offer a student help and assistance. Prevention through education, early identification and intervention, referral for treatment, and aftercare support will be emphasized in the student assistance model.
The purpose of the student assistance model is to provide students with skills necessary to avoid or cope with potential problems and to provide help for students who have problems; therefore maximizing their ability to achieve in school.
TABLE OF CONTENTS
Introduction
Student Assistance Model Team 2
How Students Can Be Referred to the
SAM Team 3
Prevention Curriculum 3
Peer Educators 3
Board of Education Policies
Youth Suicide Prevention 4
Child Abuse and Neglect 5
Smoking - Use of Tobacco Products 8
Behavior Affecting Substances 9
Drug and Alcohol Administrative Guidelines 10
with Guideline Charts 12
Flow Chart 15
Referral Form 16
Resources for Help Back Cover
STUDENT ASSISTANCE MODEL
INTRODUCTION - The Student Assistance Team, the Guidance curriculum, the DARE. Program, the Peer Education Program, and Teacher Support Team are active components of our Student Assistance Model.
THE STUDENT ASSISTANCE MODEL TEAM (SAM Team) is a multi-disciplinary team composed of school personnel. This team has been trained to understand and work on issues of adolescent chemical use, abuse, and dependency and plays a primary role in the identification and referral process. The team also provides assistance to students who may be at risk in any other area. The SAM Team meets regularly and in times of crisis on referred students to assess the nature and extent of the problem, make appropriate recommendations and provide follow-up services.
The team is composed of:
Robert Laskarzewski Middle School Principal
Barbara Bostrom School Counselor
Sheila Russolino School Psychologist
Holly Parker School Nurse
Jennifer Blevins Teacher
Larry Barlow Teacher
Sheri Wilson Teacher
Alyssa Fabry Teacher
Support Personnel to SAM:
Assistant Principal
Maryanne Leichter Special Services Coordinator
Mark E. Maynard Resident State Trooper
Trent Kaulkaus D.A.R.E. Officer
Valerie Nettleton Guidance Intern
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HOW STUDENTS CAN BE REFERRED TO THE SAM TEAM
1. Self-Referral – a student can refer himself/herself by telling any member of the SAM Team, the support personnel, teachers, or peer educators of their desire for help. A student who seeks drug-related help or advice for himself/herself or for a friend from a staff member will not receive disciplinary action. The staff member will inform the student of the availability of professional help and his/her rights in receiving such help and will encourage and support the student in seeking help.
2. Peer referral – a friend may refer you.
3. Staff/Team referral – a staff member who sees signs that you are having problems and who cares about you may make a referral.
4. Disciplinary referral - a building administrator rather than just punish you if you do something wrong, will offer you the chance to get help with whatever caused you to get into trouble.
5. Parent – a parent may contact the school and refer you if they are concerned.
WHAT WILL HAPPEN
Once referred, you will meet with a member of the SAM Team. You may be offered individual and/or group counseling. Your parents may be contacted. You may be referred to an outside agency. The SAM Team will continue to give you support when needed. (Refer to guidelines and flow chart)
PREVENTION CURRICULUM
A comprehensive drug education curriculum is taught in the middle school. The curriculum focuses on making healthy choices, refusal and decision making skills.
PEER EDUCATORS
Lebanon Middle School recognizes that most street information is learned, not from knowledgeable adults, but from one’s peers. With this in mind, our school is committed to the Peer Education Program. Peer educators go through training so that they may impart correct information to their peers, be positive role models to students in lower grade levels, and support their peers.
The Peer Educators are:
Lindsey Arigno C.J. Bergamo Patrick Birrell
Nicholas Holmes Rachel Mackewicz Morgan Meese
Kelly Pestey John Ramatowski Benjamin Strenkowski
Alyson Tacchi
Peer Advisors Are:
Barbara Bostrom Larry Barlow
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L E B A N O N LOCATOR: 5141.5
Board of Education SECTION: STUDENTS
P O L I C Y INFORMAL APPROVAL DATE: 8/25/92
FORMAL APPROVAL DATE: 9/22/92
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YOUTH SUICIDE PREVENTION
The Lebanon Public Schools are committed to the prevention of youth suicide and will support the essential allocation of school personnel and funds to a youth suicide prevention program. This commitment emanates from an appreciation that suicide and other self-destructive behaviors have become critical problems for children and youth, for families, for school personnel and for the community. Furthermore, it stems from the recognition that students who are experiencing stress or depression are less available for learning and that students who are engaging in self-destructive behaviors, including substance use and suicide attempts, are jeopardizing not only their health and well-being, but also their academic achievement. Finally, because a continuum of factors underlie many youth suicides, there are sometimes opportunities to recognize in students the potential for suicide and to intervene in order to prevent self-destructive behavior and death.
Youth suicide prevention recognizes three major components: education, intervention, and evaluation. In order for a youth suicide prevention program to be effective, the school district is committed to the following:
a learning environment that promotes the physical and mental health of students and staff;
collaboration with families and community providers in all program components for youth suicide prevention;
an educational program that is effective in reaching students, staff and parents;
high quality intervention services for students, including a Student Assistance Team at each school. The members of the S.A.M. Team, and peer coaches will receive annual training to better prepare them to provide assistance;
inter-agency cooperation that enables school personnel to identify and access appropriate community resources for use in times of crisis;
effective reintegration of high risk youth into school following a crises, hospitalization or residential treatment;
leadership and planning to ensure appropriate responses to attempted or completed suicides; and
regular evaluation and revision of the policy and procedures.
All school district personnel will act in accordance with the district’s policy, procedures and timelines whenever there is any suspicion that a student may be at risk for suicide.
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L E B A N O N LOCATOR: 5141.4
Board of Education SECTION: STUDENTS
P O L I C Y INFORMAL APPROVAL DATE: 11/9/99
FORMAL APPROVAL DATE: 12/14/99
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CHILD ABUSE/NEGLECT
Reporting Of Suspected Child Abuse/Neglect
The board of education recognizes that a student’s mental and physical health will have an affect on the student’s ability to obtain the most benefit from attending school. In order to increase the student’s ability to learn while in school, the board of education realizes the importance of identifying students who may be suffering from abuse or neglect. When any school nurse, teacher, principal, guidance counselor, paraprofessional or social worker has reasonable cause to suspect child abuse or neglect, he/she shall immediately make an oral report by telephone or otherwise to the Department of Children and Families (DCF).
Reports of abuse or neglect to DCF by the above-mentioned personnel (“mandatory reporters”) shall include the following information, if known:
the names and addresses of the child and his/her parents or other person responsible for the child’s care;
the age of the child;
the gender of the child;
the nature and extent of the child’s injury or injuries, maltreatment or neglect;
the approximate date and time the injury or injuries, maltreatment or neglect occurred;
information concerning any previous injuries to, maltreatment of or neglect to the child or his/her siblings;
the circumstances in which the injuries, maltreatment or neglect came to be known to the mandatory reporter;
the name of the person or persons suspected to be responsible for causing such injury or injuries, maltreatment or neglect; and
whatever action, if any, was taken to treat, provide shelter or otherwise assist the child.
The reporter shall submit a written report to DCF containing such information within 48 hours of making an oral report. The reporter shall also submit a written report containing such information to the superintendent of schools.
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The superintendent shall also immediately notify the child’s parent or other person responsible for the child’s care that a report of abuse or neglect has been made.
Reports to DCF should be made where a mandatory reporter in his/her professional capacity, has reasonable cause to suspect or believe that any child under the age of eighteen:
1. has had non-accidental physical injury, or injury which is at variance with the history given of such injury inflicted upon his/her by a person responsible for such child’s health, welfare, or care by a person given access to such child by such responsible person;
2. has been neglected in one or more of the following ways:
has been abandoned;
is being denied proper care and attention, physically, educationally, emotionally, or morally;
is being permitted to live under conditions, circumstances, or associations injurious to the child’s well-being; or
3. is in danger of being abused, regardless of whether there is reasonable cause to suspect or believe any such abuse has actually occurred.
When an investigation by DCF produces evidence of child abuse by a certified school employee in a position requiring certificate, the superintendent shall suspend the certified professional employee with pay and without termination of benefits, and shall notify the board of education and the Commissioner of Education or his representative of the reasons for and conditions of the suspension within seventy-two (72) hours after the suspension. If the contract of employment of a certified school employee is terminated as the result of an investigation of abuse, the superintendent shall notify the Commissioner of Education or his representative within seventy-two (72) hours after such termination.
The superintendent is authorized to delegate his or her responsibilities for receiving and making reports, notifying and receiving notification, and conducting investigations to a designee acting in his or her behalf. Under state law, the superintendent of schools is authorized to receive notice from the State’s Attorney of convictions of certified school employees for crimes involving an act of child abuse or neglect or sexual assault. DCF is responsible for all investigations involving certified school personnel.
Penalty
Under state law, any person who is required to report suspected child abuse/neglect and fails to make such a report shall be fined up to $500. Under state law, any person who knowingly makes a false report of child abuse or neglect shall be fined no more than $2,000 nor imprisoned not more than one year or both.
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Legal Risk
Under state law, any person who in good faith makes a report of suspected child abuse/neglect is immune from any civil or criminal liability.
Emergency Health Care and Reasonable Injury
When reasonable cause to suspect or believe that a child has been abused or neglect exists or when a child has a visible injury, public school personnel may make reasonable inquiry of the child regarding such suspicion or visible injury.
If a school nurse or school medical advisor is not readily available and the rendering of emergency first aid is necessary, other public school personnel who have completed a course in first aid offered by the American Red Cross, the American Heart Association, or the Connecticut Department of Health Services may render such emergency first aid to a child. In accordance with state law, any person providing such aid is not liable for civil damages for any personal injuries which result from acts or omissions by such person rendering the emergency first aid, which constitute ordinary negligence. The immunity does not apply to acts or omissions constituting gross, willful or wanton negligence.
Interviewing the Child
Public school personnel who believe that an interview in the school setting may be necessary in order to protect the child must notify DCF as early in the day as possible to provide both DCF and the school administration ample time to coordinate appropriate activities and actions. Upon receipt of such notice, DCF will advise school personnel whether the child must be interviewed in the school. If school personnel decide to retain the child after the scheduled school day in order to ensure an interview by DCF or local or state police, school personnel must attempt to notify the parents of the child, except where the alleged abuse involves the parents. School personnel may act as a disinterested party during the interview.
Preparation for the Interview
If DCF determines that a school interview is appropriate, the DCF social worker shall make efforts to call the superintendent of schools prior to the school visit with as much advance notice as possible. The DCF social worker shall provide the superintendent of schools with a DCF identification. If the DCF social worker is not known to school personnel, a verifying call to the local DCF office shall be made. If deemed appropriate by DCF or the administration, the parent or guardian of the child will be notified prior to the interview. DCF personnel are solely responsible for scheduling such interviews. If the DCF social worker does not arrive as scheduled and school personnel decide that the retention of the child beyond the school day is necessary to protect the child’s physical well-being, school personnel must attempt to notify the parents of the child that the child will be late, except where the alleged abuse involves the parents.
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The Interview
To ensure confidential communication, the school administration shall provide a private place to interview the child. As part of the investigative process, the DCF social worker may request that school personnel be present during the interview. The investigation is to be conducted solely by the DCF social worker.
The removal of clothing as part of an investigation into an injury which may have been caused by child abuse shall be done only at the request of the school medical advisor or the school nurse.
Legal Reference: §17-a-101 et seq of the Connecticut General Statutes, as amended by P.A. 96-246.
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L E B A N O N LOCATOR: 4118.232
Board of Education SECTION: STUDENTS
P O L I C Y INFORMAL APPROVAL DATE: 2/26/91
FORMAL APPROVAL DATE: 3/26/91
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SMOKING – USE OF TOBACCO PRODUCTS
In view of the Surgeon General’s report and research which has found that use of tobacco products adversely affects one’s health, and that even the non smoker is at risk upon exposure to smoke; and because the Lebanon Board of Education is committed to maintaining high health standards within its domain; and to demonstrate principles that reinforce their philosophy consistent with teaching sound health practices, the Board adopts the following policy which shall pertain to students, employees and visitors:
1. Smoking is prohibited in any Lebanon Board of Education school building or on school grounds. As used here, “smoke” or “smoking” shall mean the lighting or carrying of a lighted cigarette, cigar, pipe or similar device.
2. The use of tobacco products (i.e., chewing tobacco, snuff) in any board of education school building or on school grounds is prohibited.
3. Smoking and the use of tobacco products are prohibited on field trips, athletic contests, social activities and any event where students are supervised by board personnel.
Legal Reference: Connecticut General Statutes 1-21b Smoking prohibited in certain places – school class rooms; 53-198 school buses; 21a-242 schedules of controlled substances.
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L E B A N O N LOCATOR: 5131.6
Board of Education SECTION: STUDENTS
P O L I C Y INFORMAL APPROVAL DATE: 7/25/89
FORMAL APPROVAL DATE: 8/22/89
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BEHAVIOR-AFFECTING SUBSTANCES
The Lebanon Public Schools recognize the value and right of each individual to grow, develop, and learn in a safe, drug free environment. Substance abuse and dependency endangers the safety and well being of individuals within the school environment and will not be tolerated. It is also recognized that drug use and abuse may be indicative of serious underlying problems.
It is the policy of the schools to take positive action through education, counseling, parental involvement, medical referral, and police referral in the handling of incidents in the schools involving the possession, distribution, sale, and/or use of behavior-affecting substances. Efforts will be made to offer a student help and assistance through a kindergarten to grade twelve prevention curriculum, small group and school-wide activities, the student assistance team, community support and resources, a strong and consistent administrative and faculty effort, and rehabilitative and disciplinary procedures. Prevention through education, early identification and intervention will be emphasized.
This policy including its administrative guidelines is a coordinated effort by Lebanon Public Schools to openly and effectively respond to the potential and current uses and abuses of drugs, alcohol, and mood altering substances by members of its entire student population. The policy and guidelines shall be used by all school personnel when responding to drug, mood altering substance and alcohol related situations.
Personal privacy rights of students shall be protected as provided by law. School properties may be inspected by school authorities in the interest of maintenance, health and safety according to board policy on search and seizure.
A student who on school grounds, during a school session, or anywhere at a school-sponsored activity is under the influence of alcohol, drugs or mood altering substances or possesses, uses, dispenses, sells or aids in the procurement of alcohol, narcotics, restricted drugs, mood altering substances, or any substance purported to be a restricted substance or over the counter drug shall be subjected to the Drug and Alcohol Administrative Guidelines approved by the Lebanon Board of Education and found in the Student/Parent Handbook. In addition to the Drug and Alcohol Administrative Guidelines, students who participate in extra curricular activities will be subject to the substance abuse policies of each activity.
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Behavior Affecting Substances (continued)
This policy shall not apply to students who are using drugs prescribed by their physician in a prescribed manner. According to board of education policy JGC Administration of Medications, the parent/guardian of any student who is required to take medication prescribed by a physician during the school day shall so inform the school administration. If necessary, such medication will then be administered under the supervision of the school nurse or a designated individual.
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L E B A N O N LOCATOR: 5131.6
Board of Education
P O L I C Y ADMINISTRATIVE GUIDELINES 07/25/89
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DRUG AND ALCOHOL ADMINISTRATIVE GUIDELINES
As an integral part of Student Assistance these drug and alcohol guidelines represent one component in a district-wide effort to respond effectively to drug, mood altering substance and alcohol related situations that may occur at school or at school sponsored activities. These guidelines are intended to provide a consistent minimum disciplinary means to respond to drug, mood altering substance and alcohol related incidents.
Lebanon Public Schools will provide a safe and healthy environment for students with due consideration for their legal rights and responsibilities. The Board and its administration reserve the right to use any supplementary measures deemed necessary to control substance abuse.
DEFINITION OF TERMS
Cooperative Behavior - the willingness of a student to work with staff and school personnel in a reasonable and helpful manner, complying with requests and recommendations of the members of the Student Assistance Model Team (SAM Team).
Distributing - deliver, sell, pass, share or give any alcohol, drug, or mood altering substance, from one person to another or to aid therein.
Drug/Mood Altering Substance/Alcohol - includes any alcohol or malt beverage, any drug listed as a controlled substance, chemical, abused substance or medication for which a prescription is required under the law, and/or any substance which is intended to alter mood.
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Examples of the above include, but are not limited to: beer, wine, liquor, cigarettes and other tobacco products, marijuana, hashish, LSD, cocaine and its derivatives, chemical solvents, glue and other inhalants, barbiturates, look alike substances, and any capsules or pills not registered with the nurse.
Drug Paraphernalia - includes any utensil or item which in the school's judgment can be associated with the use of drugs, alcohol, or mood altering substances. Examples include but are not limited to roach clips, pipes, bowls, rolling papers or spoons, and razor blades.
Non-Student - a person who is not enrolled in a Lebanon Public Schools academic program.
Possession - possess or hold or constructively possess or hold, without any attempt to distribute, any alcohol, drug or mood altering substance determined to be illegal, or as defined by this policy.
Student Assistance Model Team (SAM Team) - a multi- disciplinary team composed of school personnel (administrators, nurses, counselors, selected faculty). This team has been trained to understand and work on the issues of adolescent chemical use, abuse, and dependency and plays a primary role in the identification and referral process of students coming to its attention through the procedures outlined in this policy on Behavior-Affecting Substances and its guidelines.
Uncooperative Behavior - resistance or refusal, either verbal, physical or passive, on the part of the student to comply with the reasonable request or recommendations of school personnel. Defiance, assault, deceit, and flight shall constitute examples of uncooperative student behavior. Uncooperative behavior shall also include the refusal to comply with the recommendations of the members of the Student Assistance Team.
Legal References: Connecticut General Statutes Section 10-19, 10-154a, 10-220b, 10-233 a-f, 21a-240.
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Situational/Category |
Immediate Action |
Investigation |
Notification of Parents |
Notification of Police |
Disposition Of Substance |
Rehabilitation/ Discipline |
| 1. A student is suspected of possible drug or alcohol use on or off school premises. There is no violation or physical evidence. | The student is informed of available help and encouraged to seek assistance. Staff member may contact the counselor, nurse or administration for assistance. | Limited to behavior problems. | Not applicable | Not applicable | None. Referral to the SAM Team. | |
| 2. A student contacts a staff member in regard to the drug or alcohol use of another student. | The student who contacts a staff member is assisted and encouraged to convince the student with a problem to seek assistance. The counselor, nurse or administrator may be contacted for assistance. | Not applicable | Not applicable | Not applicable | None. Referral to the SAM Team | |
| 3. A student volunteers information about personal drug or alcohol use and asks for help. | The student is informed of services available and encouraged to seek assistance. A staff member may request advice from the counselor, nurse, administrator, social worker or psychologist. | Only with the consent of the student unless there is a clear and imminent danger. | Not applicable | Not applicable. | None. Referral to the SAM team. | |
| 4. The student has a drug or alcohol related medical emergency. | The nurse will be summoned. Student may be transported to medical facility. | The building principal or his/her designee will investigate the incident. Investigation may include a search of student’s person, locker, desk or other possessions in accordance with board policy. | Yes | Yes, especially in cases where the safety of the emergency victim or school population is at risk. | Analysis will be made if warranted. | Referral to SAM Team. If there is evidence of violation, see appropriate situational category. |
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| 5. The student possesses drug paraphernalia. No evidence of use. | Administrator is summoned. Paraphernalia is confiscated. Staff member writes an anecdotal report of the incident. | Same as #4 | Yes | If warranted | Analysis, if warranted. | Referral to SAM Team. Informal hearing, up to ten day suspension or one hundred eighty-day expulsion in accordance with student disciplinary policy. |
| 6 A
student is suspected of possessing, using, or being under
the influence of drugs or alcohol on school premises
during school hours. First offense, cooperative
behavior. A student is suspected of possessing, using, or being under the influence of drugs or alcohol on school premises during school hours. First offense, cooperative behavior. |
Administrator is summoned. Staff member writes an anecdotal report of the incident. | Same as #4 | Yes, parental conference arranged as soon as possible. | Yes | Analysis will be made at the discretion of the police. | Referral to SAM Team. Informal hearing, up to ten day suspension or one hundred eighty-day expulsion in accordance with student disciplinary policy. |
| 7 A student possesses, uses or is under the influence of drugs or alcohol on school premises during school hours. First offense. Uncooperative behavior. | Administrator is summoned. Staff member writes an anecdotal report of the incident. | Same as #4 | Yes, requested to come to the school as soon as possible. | Yes | Analysis will be made at the discretion of the police. | Referral to SAM Team. Informal hearing, up to ten day suspension or one hundred eighty-day expulsion in accordance with student disciplinary policy. |
| 8 A student possesses, uses, or is under the influence of drugs or alcohol at a school related activity on/off school property. | Chaperone will contact the group advisor and administrator. The chaperone or group advisor will write an anecdotal report of the incident. | Same as #4 | Yes. The student may be sent home immediately at parental expense or detained until a parent can accompany the student. | Yes | Analysis will be made at the discretion of the police. | Referral to SAM Team. Further action as provided by the appropriate situational categories 6, 7, 11, 12 will be administered following the administrator’s investigation. |
| 9. A student possesses, uses or is under the influence of drugs or alcohol on the school bus. | The bus driver will bring the student to school and will contact the appropriate administrator. The bus driver will write an anecdotal report of the incident. | Same as #4. | Yes, requested to come to the school immediately. | Yes | Analysis will be made at the discretion of the police. | Referral to SAM Team. Informal hearing. Refer to situational category numbers 6, 7, or 11. |
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Situational/Category |
Immediate Action |
Investigation |
Notification OfParents |
Notification OfPolice |
Disposition OfSubstance |
Rehabilitation/Discipline |
| 10. A student possesses, uses or is under the influence of drugs or alcohol at another school within the district. | Staff member will contact the building administrator or staff member in charge. | Same as #4 | Yes | Yes | Analysis will be made at the discretion of the police. | Appropriate administrator will be contacted. Informal hearing. Further action as provided by appropriate situational categories may follow. |
| 11. Repeat offense of student in possession, use, or under the influence of alcohol or other drugs. | Administrator is summoned. Staff member writes an anecdotal report on the incident. | Same as #4 | Yes, requested to come to the administrator’s office immediately. | Yes | Analysis will be made at the discretion of the police. | Referral to SAM Team. Informal hearing, up to ten day suspension or one hundred eighty-day expulsion in accordance with student disciplinary policy. |
| 12. A student is distributing a drug, alcohol or controlled substance. | Administrator is summoned. Staff member writes an anecdotal report of the incident. | Same as #4. | Yes, requested to come to the administrator’s office immediately. | Yes | Analysis will be made at the discretion of the police. | Same as in #6. |
| 13. A non-student possesses, uses, is under the influence or is distributing drugs or alcohol. | Administrator or his/her designee will be contacted immediately. | Same as #4 | Not applicable | Immediate action. | Analysis will be made at the discretion of the police. | Not applicable. |
| 14. A student is in possession or using a tobacco product. | Staff member notifies administration and writes a misconduct report. | Same as #4 | If suspension is involved. | Not applicable | Product removed and disposed of by administrator. | Refer to SAM Team. Refer to board policy on use of tobacco products in Student/Parent Handbook. |
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REFERRAL FORM
STUDENT NAME: _______________________________ DATE: ______________
GRADE LEVEL: _________ PERSON REFERRING: _______________________
Please state your reason for making this referral:
Please check any of the following which you have observed in this student:
GENERAL BEHAVIORS
_____ Defiance of rules _____ Withdrawing from friends, (curfew, responsibilities, etc.) family, etc.
_____ Child feels persecuted _____ Lethargic
_____ Memory problems _____ Lying
_____ Carries a lot of money _____ Mood swings
_____ Isolating self, parents, brothers, _____ Dramatic change in attitude sisters towards rules
_____ Vagueness, secrecy about friends, _____ Erratic eating habits (too much, activities too little)
_____ Change in peer group _____ Giving away possessions
_____ Blackouts (periods of memory loss) _____ Suicide Attempt
_____ Denies responsibility for behavior, ____ Interest in Satanism (satanic
actions-blaming others music, books)
_____ Frequent physical fights _____ Declining interest in doing
_____ Frequent accidents or physical injuries things with family, spending _____ Preoccupied with “partying” time with family
_____ Sometimes unusually happy, giggly, _____ Talking about drugs (or use)
“high” for no visible reason _____ Obscene language and gestures
_____ Drug “slang” as part of vocabulary _____ Destruction of property
_____ Writing on self _____ Depressed, crying
_____ Displays items promoting illegal _____ Always borrowing money
substances _____ Is easily upset, seems “fragile”
_____ Extremely negative _____ Stealing
_____ Self inflicted injury _____ Anxious, nervous
_____ Running away _____ Few or no friends
_____ Hangs out with older kids _____ Suicide gesture
_____ Selling possessions _____ Blatant sexual behavior
SCHOOL BEHAVIORS
_____ Does not follow directions _____ Dislikes school
_____ Tardiness _____ Sleeping in class
_____ Cheating _____ Unprepared for class
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SCHOOL BEHAVIORS
_____ Decrease in class participation _____ Attendance Problems
_____ “Present” in classroom, inattentive _____ Cutting classes
_____ Frequent visits to phone _____ Frequent trips to bathroom
_____ Erratic, inconsistent performance _____ Frequent/increased suspensions
_____ Frequent/increased disciplinary _____ Frequent/increased requests to leave problems the classroom
_____ Sudden, gradual or unexpected _____ Frequent/increased visits to nurse decline in grades and achievement for various minor complaints
_____ Incomplete or missing assignments _____ Dropping out of sports, extra
_____ Disrespect towards teachers, rules curricular activities
and regulations _____ Wandering in hallways or school
_____ Inappropriate behavior in class or grounds
school _____ Keeping information about school
away from parents
PHYSICAL APPEARANCE / HEALTH
_____ Neglects personal appearance, hygiene ____ Red eyes, frequent use of eye drops
_____ Burn marks, holes in clothing _____ Chronic cough
_____ Drug-culture clothing _____ Undiagnosed health problems
_____ Hyperactive, agitated, nervous _____ Frequent nosebleed
____ Staggering, uncoordinated motion _____ Slurred speech
_____ Frequent cold-like symptoms and _____ “Black outs”
respiratory problems
_____ Bruises
ILLEGAL ACTIVITIES
_____ Vandalism _____ Housebreaking
_____ Possession of drugs _____ Robbery
_____ Possession of drug paraphernalia _____ Possession of a weapon
_____ Stopped by police _____ Sales of drugs
____ Distribution of drugs
SPECIFIC STRESSORS
_____ Suicide of someone else _____ Any unusual or unexpected
_____ Separation or divorce change in family
_____ Family alcoholism /other drug abuse _____ Unemployment within family
_____ Arrest/legal problems _____ Physical/emotional abuse
_____ Pregnancy ____ Death of a family member
____ Frequently runs away ____ Illness of family member
____ Remarriage ____ Financial strain
____ Sexual abuse ____ Recent move/new school
____ Death of a friend
Do you wish feedback on this report? Yes No
Do you wish to remain an anonymous reporter? Yes No
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