Student Assistance Program Referral (2025/26)NEHS

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If this is an emergency DO NOT COMPLETE THIS FORM, call 911 or Crisis Services at (814)456-2014.

"SAP is designed to assist in identifying issues including alcohol, tobacco, other drugs, and mental health issues which pose a barrier to a student’s success. The primary goal of the Student Assistance Program is to help students overcome these barriers so that they may achieve, advance, and remain in school" (Pennsylvania Department of Human Resources, 2019).

If you are concerned about yourself, or someone else please complete this form.

Date *

YYYY

Name of Student you are referring *

Gender of student you are referring *

Male

Female

Non-Binary/Other

Race/Ethnicity *

American Indian/Alaskan Native

Asian

Black/African American

Hispanic

Multi-Racial

Native Hawaiian or or Other Pacific Islander (not Hispanic)

White

Uknown

Grade of student you are referring *

9th

10th

11th

12th

Does this student have an IEP? *

Yes

Unknown

Your Name *

Referral Source *

Administrative, non disciplinarian

Disciplinarian

Instructional Staff (does not include guidance counselor)

Non-Instructional Staff

Self

Parent/Guardian

Peer

Safe 2 Say

Other

Primary reason for referral (Select One) *

Internalizing behaviors

Externalizing behaviors

Academic concerns

Attendance

Bullied by others/bullying perpetrator

Policy violation related to substance use

Other policy violation

Cutting-self harm

Substance use

Physical health concerns

Suicide ideation/gesture/attempt/crisis referral

Re-entry to school from out of school placement

Social concerns

Other

Additional Information

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