Student Assistance Program Referral Form
If you have a student you are concerned about, please complete this form and it will be sent directly to the Student Assistance Professional in your school building. The SAP will then take steps to follow up with the student of concern and will seek to provide services or connect the youth with an outside service provider, if appropriate.

IF YOU BELIEVE THE STUDENT IS AT RISK OF SUICIDE OR HARMING OTHERS, PLEASE IMMEDIATELY CONTACT THE SCHOOL ADMINISTRATOR AND/OR CALL THE WASHINGTON STATE SUICIDE PREVENTION LINE AT 1-800-273-8255 OR LOCAL AUTHORITIES.


Name & Role of Person Making the Referral (Confidential) *
Your answer
Would you like the student to know you referred them? *
Students First Name *
Your answer
Students Last Name *
Your answer
What grade is the student in?
Your answer
Areas of Concern / Reason for Referral
Any additional information:
Your answer
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