Student Services Referral

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IMPORTANT: If this referral is in regards to a situation involving immediate danger or risk to the care, safety, and/or well-being of a student, please contact the Guidance Department and/or administration during school hours or Lehigh County Crisis Intervention after school hours at (610) 782-3127 or 911.

If you have concerns about a student and would like to make a Student Assistance Program (SAP), Child Study, or Peer Mediation referral, please complete the attached form. You may make a referral at any time. A link to this form is available on the SMS webpage on the Student Assistance Program tab. If you are unsure as to the program most appropriate for your referral, please select "Not sure" and we will engage the appropriate resource.

Thank you for your assistance.

If you have any questions or need assistance, contact Mr. Dorward in the Guidance Department.

Student Name (Last, First): *

Grade Level *

Individual Making Referral

Identify the student services you believe is most appropriate for this student. *

Please explain as specifically as possible the reason(s) for your referral. Cite specific observable behaviors, current levels of academic functioning, and any efforts you have made thus far to address the concern or issue. If referring to the peer mediation program, please list the names of all students involved. *

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