Lake Stevens High School SAP Referral Form
If you're concerned about the behavior, health or academic changes in a student, please complete a referral to the Student Assistance Program (SAP). The SAP team is available at Cavelero Mid High School and Lake Stevens High School. The team is made up of people who are here to help you find the help you want. The team includes school counselors, an administrator, the school nurse, an intervention specialist, school psychologist and the mental health support specialist. You can make an anonymous referral for a friend or family member who attends Cavelero or LSHS. You can also refer yourself.
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Student's name
Grade
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Referral Date (mm/dd/yyyy)
Referred by (you may request anonymity at the end of the form)
Level of urgency (for emergencies, please call 911)
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Academic performance (select all that apply)
Behavior/Conduct (select all that apply)
Attendance (select all that apply)
Affect (select all that apply)
Possible alcohol, tobacco and other drug specific behaviors (select all that apply)
Comments
If you have discussed any of these concerns with this students, please comment
Have the student's parents/guardians been contacted?
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If yes, what was their response?
What other actions have you already taken?
What actions do you plan on taking?
Anonymity requested?
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May we contact you regarding this referral while maintaining your anonymity?
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Phone number
Email address
Submit
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