Request edit access
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.

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.
Email address *
Name of person completing this form
Student's First Name *
Student's Last Name *
Grade of student being referred *
What is your role? *
Have you spoken to RTII or School Counselor?
Clear selection
If known, what medical insurance does the student have?
Never submit passwords through Google Forms.
This form was created inside of East Stroudsburg Area School District. Report Abuse