24.25 SAP Referral Form
IMPORTANT: If you are concerned the student may be an immediate danger to himself, herself, or others immediately call or make personal contact with: 
Ms. Durrwachter (durrwachter.katrina@penargylsd.org)
Mr. Gerencser (gerencser.nolan@penargylsd.org)

Resources for Immediate Assistance:
Safe to Say Something: S2SS
Northampton Crisis Intervention (610) 252-9060
National Suicide Prevention Lifeline (800) 273-8255
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Email *
Student Last Name *
Student First Name *
Grade *
Referral Date *
Relationship with Referred Student *
Your Name (This is confidential and only available to SAP Team Members) *
Student Status *
School Attendance: Frequent absences from school. *
Academic: Drop in grades, failure to complete classwork/homework, change in class participation. *
Class Attendance: Frequent absences from class, visits to the nurse, guidance, restroom. *
Emotional: Mental health concerns, demonstrates odd or unusual behavior, anxious, depressed, frequently sleeps or attempts to sleep in class, mood swings, withdrawn, outbursts of anger. *
Suicidal Ideation: Writes about or draws pictures of concern, giving away personal items, talks about not wanting to deal with things. List specific reasons for concern in "other". *
Peers: Change in peer group, talks about problems or issues with other students. *
Behavioral: Disruptive, insubordinate, change in behavior. *
Power: Bullies, teases or is mean or unkind to others. *
Drugs & Alcohol: Glassy bloodshot eyes, talks about D&A, attempts to sleep in class, noticeable weight loss/gain, deteriorating personal appearance, other students comment on student D&A use. *
Family: Expresses concern over family issues. *
Other Concerns or Additional Information: Please provide specific observable behaviors, statements you heard by the student or relayed to you by another person.
I would like to speak with a SAP team member regarding this student *
A copy of your responses will be emailed to the address you provided.
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