KD SAP Referral (Student Assistance Program)

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Please fill out this form to refer any KD student to the Student Assistance Program (SAP) team. The SAP process is CONFIDENTIAL. All information you provide will remain CONFIDENTIAL within the KD team (except for crisis response situations). Thank you for sharing your concerns.

**Crisis response situations - Please contact guidance or main office immediately (during school hours), or an outside agency for immediate help (988).

What is today's date? *

YYYY

What is the student's first and last name? *

What is the student's grade level and/or age? *

What is your name (person making referral)?

What is your relationship to the student? *

Self

Parent/Guardian

Friend or Peer

School Counselor

Social Services Coord./School Psychologist

Administrator

Teacher/Coach/Support Staff

Relative/Neighbor

Staff or Community Member

Other:

What is your contact information?

What is the reason you are making a referral? *

Please check the behaviors you have clearly observed in the student you are referring. Check all that apply: *

Expression of thoughts, plan, or means to hurt self or others** (crisis response situation)

Decrease in attendance/truancy

Decline in academic grades

Disruptive, defiant, aggressive, impulsive, or violent behaviors (acting out)

Withdrawn, sad, isolating themselves from others, fearful, shutting down (moving away from others)

Expression of hatred of self and/or others, extreme guilt or shame

Change in friends or dating relationship

Change in the family (i.e. divorce, death, separation, etc.)

Substance use or discussion of use (alcohol or drugs)

Conflict within the family or peer relationships

Bullying others or being bullied

Physical health concerns

Safe 2 Say call

Behaviors that are inappropriate for the situation/event

Excessive sleepiness/lethargy

Excessive irritability/ "on edge"

Other:

Required

Please add any additional observable behaviors you would like to share.

What has been done in the past to help the student? Please share anything that you are aware of that the student has attempted or has been offered. *

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