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2021/2022 SAP Initial Referral Form (CONFIDENTIAL)
Franklin Area Jr./Sr. High School Student Assistance Program
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Student Name
Your answer
Student Grade
Choose
7th
8th
9th
10th
11th
12th
Teacher Name
Your answer
Date
MM
/
DD
/
YYYY
Reason for referral (Check all that apply)
Home/Personal Problems
Suspected Suicidal Behavior
Academic Concerns
Attendance
Re-entry Into School
Suspected Chemical Use
Violated School Policy
Suspected Eating Disorder
Other:
Student Comments:
Your answer
Attempts to resolve the situation (if applicable, check the appropriate box to indicate the steps you have taken to correct the behavior(s)).
Student Conference
Referred to counselor
Telephoned parent
Student Contract
Referred to Discipline System
Referred to Principal
Parent Conference
Other:
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