SAP Referral Form 2017-2018
The Student Assistance Program of West Perry High School believes early intervention is necessary to help students who may be experiencing mental health concerns, substance abuse problems, family and home issues, and/or peer interaction difficulties.

If you have noticed OBSERVABLE signs of physical, emotional, and/or psychological distress in one of your students, please carefully fill out the form located here.

The SAP team greatly appreciates your caring and dedication to helping our students.

Referral Made By: *
Your answer
Student Being Referred: *
Your answer
Grade Level:
Your answer
PRIMARY Referral Reason
Please check the MOST important reason for your referral.
This student is being referred for: *
Additional Referral Reasons
Additional Comments/Explanation:
Include any extra information necessary to further clarify your reasons for making this referral. Remember to use specific OBSERVABLE changes you have noticed during the time you have known this student.
Your answer
Current SAP Team Members:
Chris Rahn
Lynne Reeder (SAP Secretary)
Mandy Zeigler Heather Bell Dan Smith
Ashley McMillen Mark Easterday
Deb Foose Amanda Peachey
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