SAP Referral
This form is CONFIDENTIAL. All referrals will be discussed in a weekly SAP meeting ASAP. If you have serious concern about a student, please contact the student's school counselor immediately (in addition to submitting this form).  If there is a concern regarding the welfare of the student (a crisis such as suicide, drug or alcohol use) please contact a school counselor or administrator immediately so that home contact and interventions can be made as soon as possible.  Suspected Child Abuse please call CHILDLINE (800-932-0313) and then contact the school counselor.  A SAP referral is not the first step and should only be considered after guidance/admin contact.
Email *
Date of Referral:  *
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Completed By:  *
Student Name: *
Grade *
Age: *
Gender: *
Race: *
Required
Ethnicity *
Required
Legally Emancipated *
Special Education *
Reason For Referral - Clear Observable Academic Behaviors - Check All That Apply *
Required
Was SAP referral checklist utilized? *
Required
Strength(s) And Resiliency Factor(s) - Check All That Apply *
Required
Additional observable behaviors :  
What has been done to resolve this problem?  *
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This form was created inside of Lebanon School District.