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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. Sampson (
sampson.eric@penargylsd.org
)
Mrs. Krisukas (
krisukas.amber@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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* Indicates required question
Email
*
Your email
Student Last Name
*
Your answer
Student First Name
*
Your answer
Grade
*
Choose
9th
10th
11th
12th
Do Not Know
Referral Date
*
MM
/
DD
/
YYYY
Relationship with Referred Student
*
Choose
Teacher
Administrator
PAHS Staff Member
Parent
Friend
Other
Your Name (This is confidential and only available to SAP Team Members)
*
Your answer
Student Status
*
In Person
Virtual
School Attendance: Frequent absences from school.
*
Yes
No
Academic: Drop in grades, failure to complete classwork/homework, change in class participation.
*
Yes
No
Class Attendance: Frequent absences from class, visits to the nurse, guidance, restroom.
*
Yes
No
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demonstrates odd or unusual behavior, anxious, depressed, frequently sleeps or attempts to sleep in class, mood swings, withdrawn, outbursts of anger.
*
Yes
No
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".
*
Yes
No
Peers: Change in peer group, talks about problems or issues with other students.
*
Yes
No
Behavioral: Disruptive, insubordinate, change in behavior.
*
Yes
No
Power: Bullies, teases or is mean or unkind to others.
*
Yes
No
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.
*
Yes
No
Family: Expresses concern over family issues.
*
Yes
No
Other Concerns or Additional Information: Please provide specific observable behaviors, statements you heard by the student or relayed to you by another person.
Your answer
I would like to speak with a SAP team member regarding this student
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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