Cumberland Valley K-12 Student Assistance Program Referral Form
Please fill out this form if you have concerns about either substance abuse or mental health of any student K-12 in the Cumberland Valley School District.  The school counselor will take this referral information to the Student Assistance Team for follow up and action.

* If you are concerned about the imminent safety of a student, please make this report through Safe to Say ( for a 24/7 response.  *
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The Student Assistance Program consists of a team of caring adults in each building who work to connect students who are experiencing difficulty.  Referrals to community liaisons are made and information is shared with the parent/guardian as well as possible recommendations for services in the community.
Student Name *
Student Grade *
Student School *
Type of Concern (Any concerns about safety should be reported via Safe2Say or in person to school staff) *
Reasons for Concern *
Name of Person Referring
Phone Number of Person Referring
Email of Person Referring
Other Way to Contact You
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