Apollo-Ridge Middle School S.A.P. Referral Form

Apollo-Ridge Middle School
S.A.P. Referral Form

Please complete this confidential online S.A.P. referral Form.

Enter the name of the student you are concerned about:*

Answer required for "Enter the name of the student you are concerned about:"

What school attendance concerns (if any) do you have regarding this child?*

Answer required for "What school attendance concerns (if any) do you have regarding this child?"

Chronic absenteeism

Pattern to absences noted

Cutting class

Tardiness

Frequent visits to the school nurse

Frequent visits to the guidance counselor

None

Other:

What physical observations (if any) do you have regarding this child?*

Answer required for "What physical observations (if any) do you have regarding this child?"

Deteriorating physical appearance

Frequent cold-like symptoms (Runny nose, watery eyes, cough, etc.)

Glassy, bloodshot eyes

Slurred or slowed speech

Smelling of tobacco, alcohol, and/or Marijuana

Unexplained, frequent injuries

None

Other:

Comments (Please remember to report ONLY observable behaviors, not opinions):

Answer required for "Comments (Please remember to report ONLY observable behaviors, not opinions):"

What is your name?

You only need to enter your name if you would like to speak to a S.A.P. team member. Your name and your referral will be kept confidential.

Answer required for "What is your name?"

What is your relation to the child being referred?*

Answer required for "What is your relation to the child being referred?"

Parent

Peer/Friend

Self-referral

Other:

Please fix the highlighted areas below before submitting.