LCTI Student Assistance Program Referral Form

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Please use this form to make referrals to the SAP teams at LCTI

Email *

What is the first and last name of the student you are referring? *

Which full-day program does the student attend? *

Academic Center

CAP

This is a 1/2 day student (referrals will be forwarded to the home school SAP team)

What grade is the student in? *

9th grade

10th grade

11th grade

12th grade

What is the reason for referring this student to SAP? (Please choose the most relevant cause for this referral) *

Please describe the observable behavior(s) that prompted this referral: e.g., declining grades or failures, excessive tardiness or absenteeism, behavioral concerns, failure to attempt or complete assignments. *

What interventions have you tried with this student? *

One-on-one meeting with student

Phone call to parent

Email to parent

Referral to school counselor

Discipline referral

Required

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