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Student Assistance Program Referral Form
Please use this document to alert the DMS SAP Team to your concerns about a specific student.
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* Indicates required question
Email
*
Your email
Student Name:
*
Your answer
Student's Grade
*
6
7
8
Incoming Referral Source
*
Administrator
Instructional Staff
Non-Instructional Staff
Parent/Guardian
Peer
Self
Other:
I am concerned about this student for the following reason(s)
*
Academic Concerns
Attendance
Behavioral concerns
Bullying or Other difficulties with peers (Victim)
Bullying or Other difficulties with peers (Aggressor)
Cutting class
Self-harm (follow-up to crisis protocol)
Social concerns
Suffered recent loss/grief
Suicidal ideation/gesture/attempt (follow-up to crisis protocol)
Suspected abuse/neglect
Tobacco use (Violation of school policy OR self-reported use)
Unexplained drop in grades
Violation of school policy (D&A)
Violation of school policy (violence/weapon)
Witness/victim of traumatic event
Drug/Alcohol use (Self-report)
Other:
Required
Is there any additional information that you can share with the SAP team for this referral?
*
Your answer
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