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Student Assistance Program Referral
This form is CONFIDENTIAL. All referrals will be followed up with as quickly as possible and if contact is unable to be made with the student, you will be informed. If you have a serious concern with a student, please contact one of our school counselors, as well as submitting this form.
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Email *
Date *
MM
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DD
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YYYY
Student's name *
Grade *
Please indicate reason for referral by checking the box next to the appropriate observable behavior.
Substance Use
Classroom Behavior/Performance/Attendance
Atypical Behaviors
Comments: Please remember to report observable behavior, not opinion.
Please share any interventions you have already taken to address this concern. (i.e., conference with student, parent contact, email to guidance counselor, contact with other staff members, etc.) *
Would you like to set up a time to speak directly with the SAP Counselor about this issue?
Clear selection
Person making referral (may be anonymous). *
Relationship to student: *
Submit
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