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

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

Answer Required

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

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

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

What is your relation to the child being referred?*

Answer Required

Parent

Peer/Friend

Self-referral

Other:

Please fix the highlighted areas below before submitting.