Behavior Observation Form

	Type in your name (teacher)*

	Student name:

	Classroom Performance
	Drop in grades, lower achievement    Needs directions given individually    Doesn't ask for help    Failure to complete assignments    Short attention span, easily distracted    Cannot remember from one day to the next    Gives up easily    Other

	Additional Comments

	Personal Traits
	Lack of peer relationships    Argues with teachers/peers    Disturbs other students (hits, pushes, teases, etc.)    Intentionally inflicts pain on self (cutting, burning, etc.)    Poor hygiene    Angered by any criticism    Lack of self confidence    Rarely smiles    Change in friends    Overt sexual behavior    Withdrawn, difficulty relating to others    Talks about own drug use, or expresses drug use through drawings    Defiant    Other inappropriate social behavior (list at bottom)

	Additional Comments

	Physical Symptoms
	Smells of smoke, alcohol, pot    Lethargic    Deteriorating appearance    Sleeping in class    Many request to leave class    Glassy bloodshot eyes

	Additional Comments

	Suicidal/Crisis Indicators
	Suicidal Threat (verbal or written)    Suicide gesture or attempt    Intense relationship with friend    Goal is broken or thwarted    Dramatic upswing in mood    Preoccupation with suicide or death    Expresses desire to gain revenge or punish via deadly or hurtful means    Victim of domestic violence or rape    Family Issues    Extreme Aggression    Extreme impulsivity or immaturity    History of suicide in the family    Death of family member or friend    Putting personal affairs in order    Giving away valuable, personal items    Inquiries about donations of organs    Planning of a funeral    Preparation of a will    Talking of suicide or death (statement of intent, tired of living, family better off without me, ways to die, etc..)    Self mutilation

	Additional Comments

	Additional Behaviors
	Defiance of rules    Fighting (Verbal or Physical)    Cheating    Sudden Popularity    Obscene lanuage or gestures    Erratic behavior/mood swings    Frequent absences

	Additional Comments