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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 ATTEMPT TO follow up with the student of concern and will seek to provide services and connect the youth with an outside service provider, if necessary. IF YOU BELIEVE THE STUDENT IS AS RISK OF SUICIDE OR HARMING THEMSELVES OR OTHERS, PLEASE CALL THE WASHINGTON STATE SUICIDE PREVENTION LINE AT 1-800-273-8255 OR LOCAL AUTHORITIES.
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Name & Role of Person Making the Referral (Confidential)
Student First Name
Student Last Name
Student Date of Birth
MM
/
DD
/
YYYY
Student Phone Number
What grade is the student in?
Are you aware of the student's living situation?
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Areas of Concern / Reason for Referral
Is the student experiencing any of the following to your knowledge:
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