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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.
* Required
Email address
*
Your email
Name of person completing this form
Your answer
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Grade of student being referred
*
Kindergarten
1st
2nd
3rd
4th
5th
Unknown
What is your role?
*
School District Faculty Member/Staff Member/Administrator
Parent
Community Member
Other:
Have you spoken to RTII or School Counselor?
Yes
No
Clear selection
If known, what medical insurance does the student have?
Medical Assistance
Private
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