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.
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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
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