Gockley Student Assistance Program (SAP) Referral

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Gockley Student Assistance Program (SAP) Referral
SAP Referrals are only checked during the school day. If you are making this referral during after-school hours and your concerns are urgent in nature, please contact the Lehigh County Mental Health Crisis Hotline at (610) 782-3127 to receive immediate assistance. If there is a life-threatening emergency, call “911” or visit your nearest emergency room.
All information should be specific, descriptive, observable, and factual.

Evallese Jose *

Please check the behavior(s) you have witnessed. *

Decreased or low class participation

Easily distracted or trouble concentrating

Drop in grades/lower achievement

Low frustration tolerance

Change in attendance/tardiness

Frequent requests to visit the nurse

Increased irritability

Argues with other students

Cheating/lying

Attention seeking/disruptive behavior

Poor hygiene

Lethargic/sleeps in class

Withdrawn/quiet

Unexplained injuries

Mood swings

Other:

Required

Please elaborate on the reason(s) for the referral and any other information that would be helpful to the team.

Prior to this SAP referral, please check any actions taken to help this student. *

Spoke to student privately

Assigned a peer buddy

Parent/guardian contact

Have referred student to guidance/administration

Gave student extra time and attention

Used an individual behavioral management program with student

Sent notices home regarding behavior/academics

Other:

Required

Name and Contact information (Optional)

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