CCSD SAP Referral Form

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The Pennsylvania Student Assistance Program (SAP) is a systematic team process used to mobilize school resources to remove barriers to learning. 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.

PLEASE READ- If the individual you're referring posses and immediate risk to themselves or others, contact an administrator or Guidance Counselor.

This form is CONFIDENTIAL. All referrals will be discussed in a weekly SAP meeting ASAP.

Name and contact information of person filling out this form. (Not required)

First Name of Student being referred. *

Last Name of Student being referred. *

Student's Grade Level *

Reason for Referral (check all that apply) *

Academic Concern/ Unexplained drop in Grades

Attendance (School Day)

Behavior Concern- Internalizing (e.g. crying, withdrawing, fearful)

Behavior Concern- Externalizing (e.g. aggression, rule breaking, impulsivity, skipping class)

Bullied by Others

Bullying (Perpetrator)

Family Concern

Social Concern

Suffered recent loss

Suicide ideation/gesture/attempt

Suspected Drug and Alcohol issues or concerns

Tobacco violation or self-reported tobacco use

Transient living conditions/ Homeless

Violated school policy

Re-entry into school

Required

Please elaborate on the reason(s) for the referral and include other pertinent information that would be helpful to the team. Any information provided must be observable. *

Prior to the SAP referral, please check any actions taken to help this student. *

Discussion with Student

Phone call to Parent

Email to Parent

Conference with Parent

Referral to the Guidance Counselor

Discussion with the School Nurse

Discussion with the Principal

Other (specify in the outcome)

None

Required

Outcome of action. (if any)

I would like to speak with a member of the SAP team. *

Yes

Submit

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