Student Assistance Program - Referral Form

Student Assistance Program - Referral Form

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

"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 Date / MM / DD YYYY
Name of student you are referring: Name of student you are referring: First Last
Student's School Building:
Referring Name: Referring Name: First Last
Referral source:

Referral source: Administrative, non disciplinarian Disciplinarian Instructional Staff Self Non-instructional Staff Parent/Guardian Peer Safe 2 Say Other Other
Primary reason for referral (select one):

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 Other
Additional information: