EAST COLUMBUS MAGNET ACADEMY Counselor Referral Student Information: Referral Source: Name: __________________________________________ Teacher: _____________________________________ Grade: __________________________________________ Date: ________________________________________ Specified Student Concerns: Interventions Attempted Check all that apply: ACADEMIC _____ Declining quality of work OTHER CONCERNS _____ Erratic behavior/mood swings _____ Praise _____ Incomplete work _____ Changes in peers/friends relationships _____ Clarify rules/expectations _____ Work not handed in _____ Associates with older groups _____ Clarify consequence _____Academic failure _____ Fear of failure _____ Time out _____ Skips study sessions _____ Withdrawn, is a loner _____ Loss of privileges _____ Seeks constant adult attention _____ Detention ATTENDANCE ISSUES _____ Defensive _____ Ignore the behavior _____ Often tardy to class _____ Neglects personal hygiene _____ Peer tutor _____ Frequently absent from school _____ Depressed _____ One-on-one assistance _____ Excessive unexcused absences _____ Unexplained physical injuries _____ Reward system _____ Frequent physical complaints _____ Conflict resolution CLASSROOM CONDUCT _____ Inappropriate sexual behavior/language _____ Parent contact _____ Disruptive in class _____ Family issues _____ Office Referral _____ Inattentive/does not concentrate _____ Theft issues _____: Other: ______________ _____ Very negative attitude _____ Has had weapons _____ Inappropriate language _____ Problems in the community _____ Poor organization skills _____ Schedule concerns _____ Cheats on assignments _____ Personal/social interpersonal _____ Fights _____ Specify other: ___________________________________ Comments that may be helpful to the counselor: ______________________________________________ _________________________________________________________________________________________________ _______________________________________________________________________ For Counselors Use Only _____ Counseled student only _____ Counseled student and telephoned parent _____ Counseled student and referred to principal/designee _____ Counseled student and returned to class _____ Counseled student and referred to community agency _____ Other: _________________________________________________________________ Counselor’s Signature: _______________________________________________ Date: _______________ ECMA 08/08/19 EAST COLUMBUS MAGNET ACADEMY Counselor Referral