Student Assistance Program Referral Form 2021-22

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The Student Assistance Program is a state mandated program to identify and assist students. Students are referred regarding problem behaviors such as a decline in grades, suspected drug use or behaviors that inhibit learning. Anyone may make a referral. Referrals can be made anonymously except in the case of teachers or staff. It is expected in their professional capacity that teachers and staff identify themselves when making a referral. This information is confidential and not shared with the student

Name of person making referral (optional)

Last name of student being referred *

First name of the student being referred *

Grade of student being referred *

What is your role? *

Lakeland Faculty/Staff/Administrator

Parent

Community Member

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