Wrightsville SAP Online Referral Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for taking the time to express your care and concern about the students here at Wrightsville Elementary School.

Please use the form below to provide information about the student of concern. Please don't forget to click the submit button to ensure that we receive your responses. Unless you would like to speak with a member of the SAP team, your identity will remain anonymous

Student Name *

Student's Grade Level *

Is that child in immediate danger? *If YES and this is regarding an immediate safety concern, please call the appropriate number. Safe to Say: 1-844-723-2729 www.safe2saypa.org or use the Safe2Say mobile app; Police: 911; Crisis Intervention: 1-717-632-4900; National Suicide Prevention Lifeline: 1-800-273-8255; Crisis Text Line: Text HOME to 741741; Childline (Child abuse/neglect): 1-800-932-0313 *

Academic Performance

Decrease in class participation

Drop in grades

Does not follow directions

Easily distracted

Failure to complete assignments

Deteriorating reading skills

Deteriorating writing skills

Poor short-term memory

Poor test scores

Short attention span

Other:

School Attendance

Chronic absenteeism

Pattern to absences noted

Cutting class

Tardiness

Frequent visits to the school nurse

Frequent visits to the school counselor

Physical Observations

Deteriorating personal appearance

Frequent cold-like symptoms (runny nose, watery eyes, cough, etc.)

Glassy, bloodshot eyes

Slurred or slow speech

Smelling of tobacco, alcohol, and/or Marijuana

Unexplained, frequent injuries

Disruptive Behaviors

Attention-seeking behavior

Cheating

Crying

Defiance of rules

Fighting

Hyperactivity, nervousness

Irresponsibility, blaming, denying

Lying

Obscene language, gestures

Sudden outbursts of anger

Verbally abusive to others

Atypical Behaviors

Change in friends

Defensive (feels picked upon)

Depression

Inappropriate repsonses

Obvious mood swings

Seeking adult advice without a specific problem

Overeating

Refusal to eat

Sexual behavior in public

Significantly older/younger friends

Sudden popularity

Talks freely about drug use

Comments (Please remember to report ONLY observable behaviors, not opinions)

Would you like to speak with a member of the SAP Team?

What is your name? (You only need to enter your name if you would like to speak to a SAP Team Member. Your name and your referral will be kept confidential.)(Last Name, First Name) Example: Jones, Sally

What is your relation to the student being referred? *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Eastern York School District. Report Abuse

Forms