Grcneed To See Form

GRADUATION RESOURCE COUNSELOR

NEED TO SEE FORM School__________________________

Date________________

Student’s Name_____________________________________ Referring Person____________________________________ Reason(s) for referral____________________________________________________________

Please check relevant items: Academic Performance

Classroom Conduct

______ Current grade average_____

_______ Disruptive in class

_______ Incomplete assignments

_______ Lack of concentration

_______ Decline in quality of work

_______ Inattentive during class

_______ Underachieving Attendance

Behavior

_______ Frequent absences

_______ Hyperactive

_______ Often late to class/school

______ Withdrawn

_______ Frequent cutting of class

_______ Defiant _______ Immature _______ Seeks adult attention _______ Lethargic

List any additional information and action taken to help this student_____________________________________ ___________________________________________________________________________________________ RETURN THIS FORM TO THE GRADUATION RESOURCE COUNSELOR