SAP Referral Form 2020-2021

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The Student Assistance Program of West Perry High School believes early intervention is necessary to help students who may be experiencing mental health concerns, substance abuse problems, family and home issues, and/or peer interaction difficulties.

If you have noticed OBSERVABLE signs of physical, emotional, and/or psychological distress in one of your students, please carefully fill out the form located here.

The SAP team greatly appreciates your caring and dedication to helping our students.

Referral Made By: *

Student Being Referred: *

Grade Level:

PRIMARY Referral Reason

Please check the MOST important reason for your referral.

This student is being referred for: *

Academic Concerns

Attendance Issues

Behavioral Concerns

Body Image Concerns

Gender Identity Issues

Homelessness

Re-entry into School

Self-Harm/Injury

Self-Reported Problem

Social Concerns

Suffered Recent Loss

Suicide Ideation, Gesture, or Attempt

Suspected Child Abuse/Neglect

Suspected D&A or Tobacco Use

Teen Pregnancy/Parenting

Witness/Victim of Traumatic Event

Other:

Additional Referral Reasons

Academic Concerns

Attendance Issues

Behavioral Concerns

Body Image Concerns

Gender Identity Issues

Homelessness

Re-entry into School

Self-Harm/Injury

Self-Reported Problem

Social Concerns

Suffered Recent Loss

Suicide Ideation, Gesture, or Attempt

Suspected Child Abuse/Neglect

Suspected D&A or Tobacco Use

Teen Pregnancy/Parenting

Witness/Victim of Traumatic Event

Other:

Additional Comments/Explanation:

Include any extra information necessary to further clarify your reasons for making this referral. Remember to use specific OBSERVABLE changes you have noticed during the time you have known this student.

Mrs. Heather Bell-Guidance Counselor
Mrs. Amanda Davis-Nurse
Mrs. Kelly Eckroth-Home and School Visitor
Miss Jessica Fisk - English Teacher
Mrs. Debra Foose-Learning Support English Teacher
Mr. Cory Hoffman - Assistant Principal
Miss Lauren Meili - Guidance Counselor
Mrs. Ashley McMillen-English Teacher
Mrs. Lauren Meili- Guidance Counselor
Mrs. Kendall Pankake-Spanish Teacher
Mr. Christopher Rahn-Principal
Mrs. Lynne Reeder-English Teacher/SAP Secretary
Mr. Dan Smith-Science Teacher
Mrs. Leah Willochell - Science Teacher
Mrs. Mandy Zeigler-Guidance Counselor

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