Feaster Charter School Potential Impact Form

Feaster Charter School Potential Impact Form

Please complete the following information/checklists. Completed referrals will be accessible on the JotForm website. One form should be filled out per student per incident. Please be aware the purpose of this form is for a counselor to check in on the referred student then to determine next steps.
Date & Time
Yes- STOP AND CALL THE FRONT OFFICE to report NOW!No- continue to complete this form
Student's Full Name*

First NameLast Name
Student's Grade Level*
YesNoReferred/Waiting
Reason for Referral (What current life change are you reporting about?)*
Addressed issue with studentContacted caregiverOffered in-classroom supports (calm corner, breaks, etc.)Used Counseling LinkTree resources (found in the Feaster Elementary OneNote)Other
What potential impact have you observed and are concerned about? (check all that apply for each section below):
Failing gradesAssignments incomplete/missingTests failed/low scoresDifficulty following directionsInconsistent effort/decline in effortConsistently loses classroom privilegesDeclined attendance - please enter absences below and suspected reason for absences.Other
Defiance of school rulesDifficulty staying on taskInappropriate language, swearingWithdrawn/does not respondInattentive/day dreamsTrouble in hallwayTrouble in lunch roomVerbal outburstsRefuses to work/participateDisoriented/confusedAggressive behaviorEasily distractibleOther
Alone, lacks friendsAbusive to othersSubject of teasingInappropriate social skillsInappropriate social interestsPlays scapegoat/self-blameSudden change of friendsTries to dominate/intimidateBlames othersOlder/younger social groupOther
Low self esteemCries easily/depressedChronic complainerUnrealistic goalsWeight loss or gainTalks about drug useWide mood swingsOverreactsAppears anxious/tenseFearful of schoolTalks about death/suicidalOther
Teacher's Full Name*

First NameLast Name
Should be Empty: