SAP Referral Form
Clarion Area Jr. Sr. High
The following form is to be used when a student shows signs of distress in any of the following areas; Behavior, health, academics and/or attendance. If you feel a student is a danger to themselves or others, please contact an administrator immediately.
Individual Referring (optional)
Decrease in class participation
Short attention span, easily distracted
Drop in grades / lower achievement
Poor short term memory
Does not complete assignments
Academic Performance Current grade/comments
Deteriorating personal appereance
Frequent cold like symptoms
Glassy or blood shot eyes
Unexplained/frequent physical injuries/bruises
Sleeping in class
Odor of smoke
abnormal weight loss
Additional Health Comments
Class Attendance (# of Absences/Tardies)
Frequent requests to leave classroom
Late to class
Defiance of rules
Exhibits self-abusive behavior
Irresponsible; blaming; denying
Inappropriate language, gestures
Change in Friends
Withdrawn, difficulty relating to others
Talks, writes about drugs
Additional Comments Behavior
Send me a copy of my responses.
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