Student Assistance Program (SAP)

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Teacher/Staff Form for HS only
If this referral is a true emergency and you require immediate assistance, please call Mobile Crisis 855-634-4672 available 24 hours a day or 911. Please note that all online, SAP referrals are received and addressed during regular school hours only – when school is in session.

Date & Time

Student's Name

Student's Grade

Name of Person Making Referral (Optional)

Reason for Referral

Class Attendance Information

Number of days absent from class

Number of days late to class

Number of class cuts

Number of requests to visit restroom, nurse, or counselor

Strengths

Please check all that apply

Able to work independently

Participates extra curricular activities

Works well in a group

Demonstrates a desire to learn

Demonstrated good reasoning and decision making

Can accept redirection

Considerate of others

Exhibits leadership skills

Good communication skills

Cooperative

Good interpersonal skills

Displays positive values

Respects appropriate boundaries

Constructive use of time

Helps others

Likes school and staff

Strives to do their best

Other:

Academic Performance

Current grade in class

Please check all that apply

Performing at or above ability

Performing below ability

Decrease in class participation

Failure to complete homework

Cheating in class

Drop in grades

Failure to complete in-class assignments

Poor test scores

Will not accept assistance or help

Unprepared for class

Difficulty retaining new information

Reading below grade level

Doesnt care about academic performance

Easily frustrated

Off task in class

Short attention span

Other:

Comments

Disruptive Behavior/Illicit Activities

Number of detentions assigned

Please check all behaviors that you have observed

Verbally abusive

Fighting

Sudden outbursts of anger

Use of profane words or gestures

Hitting, pushing others

Disturbing other students

Refusal to accept responsibility for actions

Easily distracted

Easily influenced by others

Repeated violations of classroom rules

Involvement in theft in classroom

Involvement in destruction of property in classroom

Carrying large amounts of money

Talking about drugs or drug paraphernalia

Physical Attributes

Please check all that apply

Noticeable change in weight- loss

Noticeable change in weight- gain

Sleeping in class

Complaining of feeling sick

Glassy/bloodshot eyes

Unexplained bruises or physical injuries

Poor motor skills

Frequent cold-like symptoms

Smelling of alcohol

Smelling of marijuana

Slurred speech

Poor hygiene

Student expressing concern about physical health

Fatigue

Disoriented

Evidence of self-injury or self-harm

Headaches

Food issues

Atypical Behavior

Please check all that apply

Associates with younger or older social group

Openly talks about alcohol or drug use

Expresses desire to punish or seek revenge

Wears drug/alcohol related clothing

Wears inappropriate or revealing clothing

Inappropriate sexual verbalization

Expresses involvement in the occult

Expresses involvement in hate groups

Trouble getting along with peers

Withdrawn/loner

Difficulty making decisons

Expresses hopelessness, worthlessness

Expresses anger toward authority figure

Tells lies

Criticizes self or others

Seeks constant reassurance or attention

Expresses inappropriate entitlement

Threatens or harasses others

Cries often

Expresses ethnic slurs- verbally or written

Expresses fear or anxiety (explain)

Sudden change in behavior (explain)

Acts sexually inappropriate (explain)

Home/Family Indicators

Please check all that apply according to your awareness

Recent divorce or separation of parents/guardians

Absence of caregiver

Job loss of family member

Fear of or refusal to go home

Recent death of family member or close friend

Hangs around school for no apparent reason

Homeless, living in shelter or with relatives/friends

Use of alcohol or drugs by family member(s)

Living in foster care

Living with adult other than natural parent

Other:

The SAP Team thanks you for your help.

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