Online SAP Referral Form

If you’re concerned about the behavior, health, or academic changes in a student, a referral to the Student Assistance Program (SAP) may be indicated. Some of these concerns may be directly addressed by staff, concerned peers, or other community members, but should you feel there is a need for additional services or follow-up, a referral to the SAP is recommended.

Student First Name: (Required) Last Name: (Required) Grade: (Required)
Referral Date: Referred By: (Required)
Level of Urgency: FYI

A. Academic Performance:

Decline in quality of work
Decline in grade earned
Incomplete work
Work not handed in
Failing in this subject
Capable of better work


B. Behavior/Conduct

Defiance; breaking rules
Frequently needs discipline
Throwing Objects
Defiance of authority
Verbally abusive
Obscene language, gestures
Sudden outbursts of temper


C. Attendance

In-School absenteeism (skipping)
Tardiness to class
Frequent visits to sick room
Frequent signing out of school early
Frequent visits to lavatory
Frequent visits to counselor


D. Affect

Lack of concentration
Lack of motivation
Sleeping in class
Impaired memory
Extreme negativism
Hyperactivity nervousness
Erratic behavior day-to-day
Change in friends and/or peer group
Sudden, unexplained popularity
Mood swings
Seeks constant adult contact
Seeks adult advice without a specific problem
Time disorientation
Apparent changes in personal values
Depression, low affect
Withdrawal: a loner; separateness from others
Fantasizing; daydreaming
Compulsive over achievement;
preoccupied with school success
Rigid obedience
Change in personal appearance


Possible Alcohol, Tobacco and Other Drug Specific Behaviors

Peer Reported
Self Reported
Witnessed Suspected  
Selling; Delivering
Possession of ATOD
Possession of drug paraphernalia
Use of alcohol, drugs
Physical signs, symptoms
Associates with apparent drug users
Talks freely about drug use; bragging
Wears drug related jewelry
(Please indicate specifics in the below area)



If you have discussed any of these concerns with this student, please comment.

Have the parents been contacted?

-- If Yes, what was their response?

What other actions have you already taken?

What actions do you contemplate taking?

Other comments?


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