SAP Referral Form

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SAP Referral Form

THIS FORM IS CONFIDENTIAL- For immediate concerns please follow Crisis protocol if needed by contacting the nurse at extension- 31907 or front office at extension- 31900

Date *

YYYY

Student Being Referred (First, Last) *

Grade *

Reason for Referral *

Attendance (Class tardies/Class absences)

Involvement in Legal System

Tobacco violation or self reported tobacco use

Bullying: Aggressor

Bullying: Victim

Suspected drug and/or alcohol issues

Witness/Victim of Traumatic Event

Skipping Class

LGBTQIA+ Support

Behavioral Concerns

Parent Incarceration

Homelessness

Gambling

Family Concern

Teen Pregnancy

Self-Harming Behavior

Suffered Recent Loss

Social Concern

Runaway

Unexplained drop in grades

Transient living conditions

Suspected child abuse/neglect

Suicidal ideation/gesture/attempt

Violated school's weapons policy

Any additional information that would be helpful to know regarding the referral student. (Please provide additional details below, the more information given the better to ensure the student is connected to supports appropriately)
*

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