Student Assistance Program (SAP) Initial Referral Form 2021-2022
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. It is a method for trained school personnel to intervene and refer these students to appropriate school and community services, as well as appropriately following up after the referral. **If the concern is academic, please refer to our Instructional Support Team. If you feel low grades are a symptom of something else (i.e. grief, depression, outside factors, etc.) please complete this form.

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.
Sign in to Google to save your progress. Learn more
Name of person making referral (optional)
Last name of student being referred *
First name of student being referred *
Grade of student being referred *
What is your role? *
If this is a parent referral, please add your preferred contact information (phone and/or email).
Month of referral
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Valley View School District. Report Abuse