Summit Hill Junior High
SOS
Student Referral
Today’s date:
I would like to speak with: (circle)
Mrs. Lind
Mr. McGuckin
Mr. Barnas
Mrs. Goebel
Mrs. Kelly
Mrs. Lane
Mrs. Madonia
Mrs. Roney
Mr. S
This referral is about (circle):
Name:
me
my friend
other
Grade:
Who needs our help?
Please circle your concern:
Alcohol
Cigarettes
Drugs
Physical Abuse
Suicide Threat
Depression
Family Problem
Teasing
Runaway Threat
Sexual Abuse
Gang Involvement
Bullying
Grades
Illness
Sexting
Facebook
Other:
What makes you think the person you are reporting has a
problem?
Sign your name (only if you want to)