Student Assistance Referral Form If this is an emergency DO NOT COMPLETE THIS FORM, call 911 or Crisis Services at (814)456-2014.

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"SAP is designed to assist in identifying issues including alcohol, tobacco, other drugs, and mental health issues which pose a barrier to a student’s success. The primary goal of the Student Assistance Program is to help students overcome these barriers so that they may achieve, advance, and remain in school" (Pennsylvania Department of Human Resources, 2019).

If you are concerned about yourself, or someone else please complete this form.

Date: *

YYYY

Name of student you are referring: *

Referring Name:

Referral source: *

Administrative, non disciplinarian

Disciplinarian

Instructional staff

Self

Non- Instructional staff

Parent/guardian

Peer

Safe 2 Say

Other:

Primary reason for referral (select one) *

Internalizing behaviors

Externalizing behaviors

Academic concerns

Attendance concerns

Bullied by others/bullying perpetrator

D&A policy violation

Other school policy violation

Substance use concerns

Family concern

Physical health concerns

Suicide ideation/gesture/attempt/crisis referral

Re-entry to school from out of school placement

Social concerns

Other

Additional Information:

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