Student Assistance & Prevention Program Referral

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Welcome to the Botetourt County Public Schools SAPP Program!

As it is our goal to support our student's mental health needs within our schools, you may complete this form to help us be aware of what those needs may be.

If this is a crisis or an emergency, please be sure to refer the student of concern to the appropriate adult and/or professional or call 911.

Please feel free to access the following resources below:

Crisis Text Line

988 Suicide & Crisis Lifeline

Roanoke Area Youth Substance Abuse Coalition

Botetourt Prevention Coalition

211 Virginia

For any further questions or concerns, you may email your designated SAPP Counselor:

Ms. Megan DeHart (Read Mountain Middle School & Lord Botetourt High School)

mdehart@bcps.k12.va.us

Ms. Myrrh Manaytay (Central Academy Middle School & James River High School) mmanaytay@bcps.k12.va.us

Referral Date: *

YYYY

School *

Student's Last Name, First Name: *

Student's Grade Level: *

Reason for Referral: Check all that apply *

Student recently experienced a loss (death of family member or friend) or lives with someone chronically/terminally ill

Student shows sign of depression or possible self-harm

Student talks about problems at home

Student is believed to be having difficulties with others (peer conflict, assertiveness skills, etc.)

Student exhibits inability to cope with emotions appropriately (anger management)

Student is believed to be in an unhealthy relationship (romantic relationship, friendship, etc.)

Suspicion of substance use/abuse (Talks freely about their use)

Suspicion of substance use/abuse (Other students talk about the student's use/abuse of substances)

Suspicion of substance use/abuse (physical signs indicate possible use/abuse)

Other:

Required

Person referring would like to: *

I wish to remain anonymous

I am willing to be asked follow-up questions if needed

The student may be informed that I made this referral

Required

Name of person referring: *

Additional Information that would be helpful for SAPP Counselor to know:

Submit

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