ZHS Intervention Referral
ZHS Intervention Referral
Staff Member Name
*
Staff Member Email
*
Student Name
Student Name
*
First
Last
Student Number
*
Student's Grade Level
*
9
10
11
12
Subject
*
Period
*
1st
2nd
3rd
4th
5th
6th
Other
Check all that apply:
*
Check all that apply:
Excessive absences
Continuous refusal to comply with electronics policy
Excessive tardies
Disengaged (out of the norm for this student)
Consistently disengaged in class
Skipping class
Classroom behavior
Social/Emotional/Physical welfare (non-emergency)
Medical issues
Financial need (food, housing, clothing, etc.)
Other
Other
Briefly explain the checked issue(s). PLEASE REMEMBER TO BE PROFESSIONAL. THIS FORM IS A PUBLIC RECORD.
Please list any relevant interactions you have had with or concerning this student ( i.e. parent contact through phone or email, seating changes, conferences, discipline referrals, or referrals to guidance, SSAP, Behavior Specialist, etc.).
*
SIT Team Use Only