Senior High School SAP Referral

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Referrals of students to SAP are based on observable behaviors. Observable behaviors are defined as behavior which can be noted thorugh one of the senses. Please do not include feelings or intentions which are inferred from other behaviors. Please check appropriate concerns below then submit this form.

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Student Name

Grade

Referred By (Optional)

Academic Concerns

Failing or near failing grades

Failure to complete homework

Failure to complete in-class assignments

Poor test scores

Drop in grades

States a disinterest in academics

Easily frustrated

Short attention span

Decrease in participation

Cheating

Other:

Emotional Observations (Check all that apply)

Recent death of friend/family member

Writing or drawing that reflects death or revenge

Often criticizes self or others

Other:

Behavioral Concerns

Disruptive classroom behavior

Withdrawn/loner

Fighting/hitting

Verbally abusive

Lying

Inappropriate dress

Other:

Physical Observations (Choose all that apply)

Sleeping in class

Poor hygiene

Frequent cold-like symptoms

Noticeable change in weight

Appears disoriented

Other:

Attendance Concerns

Often absent

Often tardy

Repeated visits to the restroom, health room, or school counselor

Other:

Additional Observable Behaviors and Reasons for Referral

Submit

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