Student Assistance Program (SAP) Initial Referral Form
The Student Assistance Program is a state-mandated K-12 program designed to assist school personnel in identifying issues which pose a barrier to a student's success.

Anyone may make a SAP referral. Referrals may be made anonymously. The information contained in this referral will remain CONFIDENTIAL among SAP team members and families involved unless the SAP team determines that the student or others are in any danger. Appropriate personnel and/or authorities will be notified if a student is in danger of harming him/herself or others or if there is suspected abuse. In addition, please note that parents/guardians will have access to this referral at their request. We ask that discussion of this referral and its contents be avoided.

**Please note that the SAP team only checks for referrals once a week. If you feel that this student or anyone else is in IMMEDIATE DANGER, please contact an administrator, a school counselor, emergency personnel, or other trusted adult in the building.**

Name of person making referral (optional)
Your answer
Last name of student being referred *
Your answer
First name of student being referred *
Your answer
Grade of student being referred
What is your role? *
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