Date:________

To: Student Assistance Team
From: (name)  _________________________ Relationship to student  ___________
Regarding (name of student) ______________________  Grade _____

Reason for Referral
Please explain why you are referring the student in the appropriate sections below.  
Describe your specific concerns with examples, if possible.

Academics _____________________________________________________________
_______________________________________________________________________

Attendance _____________________________________________________________
_______________________________________________________________________

Behavior _______________________________________________________________
_______________________________________________________________________

Physical health ___________________________________________________________
_______________________________________________________________________

Emotional health _________________________________________________________
_______________________________________________________________________

Relationships with family and/or friends ________________________________________
_______________________________________________________________________

Alcohol and/or drug use ___________________________________________________
_______________________________________________________________________

Other _________________________________________________________________
_______________________________________________________________________

Your signature ________________________
Your daytime phone number ________________

Please print this form, fill it out, and then put this referral in an envelope marked:
STUDENT ASSISTANCE TEAM-CONFIDENTIAL
Please hand-deliver this referral to the Guidance office or mail it to:
(Name of Counselor?) Guidance Office, Marple Newtown High School. Etc.
If you have any questions about making a referral, please call (Name, phone number.)  
A member of the Student Assistance Team will call you within 48 hours to discuss the referral.