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Student Assistance Program East Stroudsburg Area School District Referral Form for Smithfield Elementary
The Student Assistance Program is a state-mandated K-12 program designed to assist school personnel in identifying issues including alcohol, tobacco, other drugs, and mental health issues which pose a barrier to a student's success.

Anyone may make a SAP referral. Referrals may be made anonymously except in the case of teachers or staff. It is expected that teachers and staff identify themselves when making a referral when working in their professional capacity. This information is confidential and not shared with the student.

IMPORTANT ** PLEASE READ**
Please note that if you have concerns regarding the immediate welfare of a child during the school day, such as suicidal ideations, self harm, or possession of weapons or drugs, discontinue this process and immediately contact a counselor or administrator. For similar concerns outside of school hours, please call 911.

Name of person making referral
Your answer
Last name of student being referred *
Your answer
First name of student being referred *
Your answer
Grade of student being referred *
What is your role? *
Have you spoken to RTII or School Counselor?
If known, what medical insurance does the student have?
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