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Student Assistance Program Referral Form
Smethport SD SAP Team
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* Indicates required question
Email
*
Your email
Student's Name
*
Your answer
Grade
*
7th
8th
Freshman
Sophomore
Junior
Senior
Please check the behavior(s) you have witnessed:
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Decreased or low class participation
Easily distracted or trouble concentrating
Decrease in the quality of work
Poor short-term or long-term memory
Low frustration tolerance
Change in attendance/tardiness
Frequent requests ot leave the room
Frequent request to visit nurse
Changes in extracurricular activities
Increased irritablitily
Argues with other students
Cheating
Change in friends
Does not follow teacher instructions
Drastic changes in appearance
Observed talking about drinking alcohol or using controlled substances
Required
Strength(s) and resiliency factor(s):
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Is creative
Considerate of others
Strives to achieve his/her best
Able to work independently
Exhibits leadership
Can accept re-direction
Good communication skills
Appears to like and be connected to school
Demonstrates good social skills
Other
Required
Additional observable behaviors:
*
Your answer
What has been done to resolve this problem? Please explain and provide dates.
*
Your answer
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