SAP Referral Form

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SAP Referral Form - APHS

This letter is meant to remind our academic community of a program at Academy Park called SAP (Student Assistance Program). Please see the below description of the SAP program and reach out to a faculty member or the guidance department if you think the SAP program can help your child with any obstacle they may be currently facing.

What is SAP?
SAP (Student Assistance Program) is designed to identify students that are struggling with an array of issues including mental health, emotional, family, academic, issues with peers, low self-esteem, bullying, poor decision making, and at risk behaviors. At risk behaviors include, but are not limited to, tobacco use, alcohol, drugs, sexual activity or illegal behaviors. If you are not sure if an issue would warrant a SAP referral please do not hesitate to contact the SAP team to inquire if your concern is appropriate for SAP. If it is not appropriate for SAP we will guide you in what course of action you can take to address your concern.

The SAP goal is to remove any barriers that may hinder a student's success; academically, physically, mentally and emotionally so they are successful in both their school and personal careers.

Student Behaviors Appropriate For A SAP Referral
· Academic decline
· Frequent visits to nurse and/or school counselor
· Decreased attention span
· Observable expressions of anger, tears
· Bullying behavior or frequently being bullied
· Frequent peer conflicts
· Observable behaviors such as overheard conversations about alcohol or other drugs, parties where drugs were present, or fears about a fellow student’s use of mood altering substances. Smell similar to marijuana on a student and/or belongings
· Observable behaviors such as overheard conversations about feeling very sad or depressed
· Observing a significant weight loss or weight gain
· Observing frequent trips to the restroom
· Observing a distinct behavior change or change of friends
· Observing a drug-related or satanic-related language or drawings
· Observing glassy eyes, red eyes, agitation, loss of interest in academic and extracurricular activities, rash around nose/mouth, chemical smell

Teacher/Student/Parent-Guardian Name (WHO IS MAKING THE REFERRAL?) *

Date *

YYYY

Student Last Name *

Student First Name *

Grade *

I am referring this student because he or she has exhibited behaviors, which markedly affect his or her academic performance and social interactions at Academy Park.Please check ALL statements, which represent the student’s behavior at this time: *

Unexplained Gaps of Time

Trying to Excuse Self from Class

Recent Dramatic Change in Appearance

Disruptive in Class

Hostile or Argumentative

Inability to remain focused

Unexplained mood changes

Does not keep appointments or meet responsibilities

Loss of interest in academics

Inappropriately loud

Falls asleep in class

Non-responsive and unengaged

Draws or models drug paraphernalia

Speaks openly of drugs or alcohol

Other (describe below)

Required

Please check any of the below SAP groups that you think might help this student:

Grief/Loss

Coping Skills

Family Issues

Social Skills

Healthy Relationships

Please provide a brief description of the behaviors that you have indicated above: *

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