Referral to Student Assistance Team
Referral to Student Assistance Team

Student's Name: 

Date of Birth: 

Grade Level: Kindergarten 10 11 12 




School:  Jr High Sr High Elementary

Source of referral: 

Date of report:  

Numbers 1 through 4 are to be completed by the referring teacher/parent prior to the fist Student Assistance Team meeting.


1. Describe the reason(s) for referral, including the rate at which the problem behavior occurs (for example: This student reads 68 out of 100 words correctly. This student completes 1 out 10 homework assignments). 

2. Summarize the information you received from the student's parent(s) that is relevant to this referral:

3. Health History:

A. Results of most recent school vision screening:

Date of vision screening: 

Pass      Fail


B. Results of the most recent school hearing screening;


Pass        Fail

C. List other pertinent health factors, including any medications this student is taking:

4. Describe this student's strengths: 



Security Measure