SAP Referral Form

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Student's Name* This field is required.
First Name
Last Name
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Date
Date
Month
Day
Year
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Grade Level* This field is required.
Please Select
Please Select
K
1
2
3
4
5
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Student's Teacher
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Your Relationship to the Student:* This field is required.
Please Select
Please Select
Parent
Family Friend
School Employee
Other
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Your Name* This field is required.Your referral is confidential and will not be shared with the student or family.
First Name
Last Name
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E-mail
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REFERRAL REASON* This field is required.Scroll down to see all options.
(Select One)
(Select One)
Academic Concern
Attendance (School Day)
Behavior Concern-Internalizing (e.g., crying, withdrawal, fearfulness)
Behavior Concern-Externalizing (e.g., aggression, rule-breaking, impulsivity)
Bullied by Others
Bullying (Perpetrator)
Continuation of case from another SAP team
Family Concern
Gambling
Homelessness
Involvement in legal system
Military Connectedness
Parent Incarceration
Runaway
Self-harm, injury (follow-up to crisis plan)
Skipping Class
Social Concern
Suffered recent loss
Suicide ideation/gesture/attempt (follow-up to crisis plan)
Suspected child abuse/neglect
Suspected Drug and Alcohol Issues
Teen Pregnancy
Tobacco violation or self-reported tobacco use
Transient Living Conditions
Unexplained drop in grades
Violated School Policy (other)
Violated school policy, D&A
Violated school policy, violence/weapons
Witness/victim of traumatic event
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REFERRAL REASON* This field is required.Scroll down to see all options.
(Select One)
(Select One)
Academic Concern
Attendance (School Day)
Behavior Concern-Internalizing (e.g., crying, withdrawal, fearfulness)
Behavior Concern-Externalizing (e.g., aggression, rule-breaking, impulsivity)
Bullied by Others
Bullying (Perpetrator)
Continuation of case from another SAP team
Family Concern
Gambling
Homelessness
Involvement in legal system
Military Connectedness
Parent Incarceration
Runaway
Self-harm, injury (follow-up to crisis plan)
Skipping Class
Social Concern
Suffered recent loss
Suicide ideation/gesture/attempt (follow-up to crisis plan)
Suspected child abuse/neglect
Suspected Drug and Alcohol Issues
Teen Pregnancy
Tobacco violation or self-reported tobacco use
Transient Living Conditions
Unexplained drop in grades
Violated School Policy (other)
Violated school policy, D&A
Violated school policy, violence/weapons
Witness/victim of traumatic event
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ACADEMIC PERFORMANCE:Scroll down to see all options. Skip if unknown.
Decline in quality of work
Decline in grade earned
Incomplete work
Work not handed in
Failing in this subject
Capable of better work
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BEHAVIOR, CONDUCT:Scroll down to see all options. Skip if unknown.
Defiance; breaking rules
Frequently needs discipline
Fighting
Throwing Objects
Defiance of authority
Verbally abusive
Obscene language, gestures
Sudden outbursts of temper
Vandalism
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ATTENDANCE:Scroll down to see all options. Skip if unknown.
Truancy or Risk of Truancy due to Unexcused Absences
In-School absenteeism (skipping class)
Tardiness to class or school
Frequent visits to nurse
Frequent signing out of school early
Frequent visits to the bathroom
Frequent visits to counselor
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AFFECTScroll down to see all options. Skip if unknown.
Inattentiveness
Lack of concentration
Lack of motivation
Sleeping in class
Impaired memory
Extreme negativism
Hyperactivity nervousness
Erratic behavior day-to-day
Change in friends and/or peer group
Sudden, unexplained popularity
Mood swings
Seeks constant adult contact
Seeks adult advice without a specific problem
Time disorientation
Apparent changes in personal values
Depression, low affect
Defensiveness
Withdrawal: separates from others
Fantasizing; daydreaming
Compulsive over achievement; preoccupied with school success
Perfectionism
Rigid obedience
Change in personal appearance
Other
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PARENT COMMUNICATION
Parent is aware of the concern.
Attempts to contact parents were unsuccessful.
There have been no attempts or parent information is unknown.
Other
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Please describe the current problem, including your concerns:
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If you have an image, PDF or other supporting documentation you wish to share, you may upload it here:
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Thank you for taking the time to share your concern. The SAP Team will review this referral and seek parent participation in the process. Your identity will be kept confidential.
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