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Del Rio Referral
Student Information
First Name
Last Name
Age
Gender
Please Select
Male
Female
Campus
Del Rio High School
Del Rio Freshman
Del Rio Middle School
SGLC
ACAP
Please Select
Grade Level
Seventh
Eighth
Freshman
Sophmore
Junior
Senior
Please Select
Student Cell Phone Number
Signed release form on file?
Yes
No
Parent's Name
Parents Phone Number
Referral Information
Situation Level
Please Select
Red - Attempted suicide
Red - Overall threat to hurt oneself and others
Red - Major disruption of the campus
Purple - Discussion of death or suicide
Purple - Repeated high risk-taking behavior; such as, abusing alcohol and drugs, reckless driving, or sexual promiscuity
Purple - Increase in talking -talks too much, too fast, changes topics too quickly, and cannot be interrupted
Purple - Student admits to having a problem with drugs or alcohol but is not under the influence
Purple - Change of appetite with either significant weight loss (when not dieting) or weight gain
Purple - Unrealistic highs in self-esteem - for example, a teenager who feels all powerful or like a superhero with special powers
Purple - Great increase in energy and the ability to go with little or no sleep for days without feeling tired
Purple - Delusions and/or hallucinations- Hallucinations are usually auditory and may include hearing voices speaking in the third person
Blue - A drop in school performance
Blue - A change in groups of friends, delinquent behavior, and deterioration in family relationships
Blue - Social withdrawal; student isolates or withdraws from others
Blue - Student is hitting objects, threatening others, or walking out of class
Blue - Distractibility - the teen\'s attention moves constantly from one thing to the next
Blue - Loss of enjoyment in favorite activities
Blue - Frequent complaints of physical illnesses such as headaches or stomach aches; low energy level, fatigue, poor concentration, boredom
Blue - Fidgets or squirms; moving constantly- fingers, hands, arms, feet or legs
Blue - Loses school supplies and forgets to turn in homework; has trouble finishing class work and homework; daydreams or seems to be in another world
Blue - Blurts out answers in class
Blue - Leaves his or her seat and runs around
Blue - Talks when others are talking
Blue - Walks runs or climbs when others are seated
Blue - Doesn’t finish things; gets bored after a short time
Yellow - Student expresses problems at home or with family
Yellow - Student has experienced a recent loss or major life change (divorce of parents, move, eviction, etc)
Yellow - Change in sleeping patterns (such as trouble falling asleep, waking up in the middle of the night, early morning awakening, or sleeping too much)
Yellow - Student isolates or withdraws from others
Yellow - Loss of interest in activities formerly enjoyed
Yellow - Loss of energy, fatigue, feeling slowed down for no reason, "burned out"
Yellow - Feelings of guilt and self blame for things that are not one\'s fault
Yellow - Inability to concentrate and indecisiveness
Yellow - Feelings of hopelessness and helplessness
Yellow - Moodiness-severe changes in mood-either unusually happy or silly, or very irritable, angry, agitated or aggressive
Yellow - Major change in eating or sleeping patterns, such as oversleeping or overeating
Length of time behavior has been exhibited
Behaviors of Concern
Submitter Information
Reffered By
Counselor
Teacher
Staff Member
Parent
Student
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Your First Name
Your Last Name
Your Phone Number
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