Riverside Elementary Student Assistance Program (SAP) Initial Referral Form 2017-2018

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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.

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.

Email *

Name of person making referral *

Last name of student being referred *

First name of student being referred

Homeroom Teacher of student being referred *

Grade of student being referred *

What is your role? *

School District Faculty Member/Staff Member/Administrator

Parent

Community Member

Other:

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