Smethport Area Elementary School

Smethport Area Elementary School

414 S. Mechanic St., Smethport, PA 16749 (814)887-5012. Fax (814)887-5540

Confidential Elementary SAP Referral Form

To be filled out by a referring staff member and presented at a regular SAP team meeting

Date:______

Student Name:______Grade:______

Homeroom Teacher:______

Referring Staff Member:______

Parent Contact Information:______

Regular Ed:.______Gifted:______Special Education:______504 Plan:______

Learning Support:______

Life Skills Support:______

Speech&Language:______

Emotional Support:______

Areas of Concern:

Academic______Behavioral______Social/Emotional______Other:______

Reason(s) for concern(observable, factual information):

Thank you for your referral. This student has been entered into the SAP process. Please contact Mr. Rondinelli or Mrs. Newton regarding questions about this process.

Smethport Area Elementary School

414 S. Mechanic St., Smethport, PA 16749 (814)887-5012. Fax (814)887-5540

Confidential Consent Form for Elementary SAP

Dear Parent/Guardian:

Your child, ______has been referred to the Smethport Elementary Student Assistance Program (SAP). This program provides various support services designed to meet your child’s academic, health and human services needs. A team of school personnel and /or community agency professionals will assess your child’s needs and offer appropriate recommendations for in-school and/or out of school services. Please assist us in aiding your child by signing and returning this consent form to the Guidance Office at the school in the enclosed envelope. If you have any further questions or concerns, please contact Mr. Rondinelli or Mrs. Newton. Thank you.

______I give permission

______I do not give permission

______

Signature of Parent/Guardian Date

______

Signature of SAP team member Date

This consent shall remain in effect from the date signed until the end of the current school year.

Smethport Area Elementary School

414 S. Mechanic St., Smethport, PA 16749 (814)887-5012. Fax (814)887-5540

Confidential SAP Information Form

Student Name:______Date:______

Completed by:______Return to:______

Please check all that you have personally observed pertaining to this student.

Academic PerformanceAttendance

_____Present grade_____Tardiness to school(how many)_____

_____Drop in grades, lower achievement_____Absent(how many)_____

_____Decrease in class participation_____Frequent gym excuse

_____Failure to complete assignments_____Frequent visits to nurse

_____Short attention span, easily distracted_____Frequent visits to guidance office

_____Poor short term memory_____Frequent visits to restroom

_____Does not follow directions_____Other

_____Off task behavior

Comments:Comments:

Disruptive BehaviorAtypical Behavior

_____Defiance of rules_____Change in friends

_____Irresponsibility,blaming,denying_____Erratic behavior

_____Fighting_____Sudden popularity

_____Cheating_____Much older or younger social group

_____Sudden outbursts of anger_____Sexual behavior in public

_____Verbally abusive to others_____Disorientated

_____Obscene language or gestures_____Unrealistic goals

_____Crying_____Inappropriate responses

_____Nervousness _____Appears sad or depressed

_____Hyperactivity_____Seeks frequent adult attention or feedback

_____Attention-seeking behavior_____Defensive

Disruptive Behavior Cont.’dAtypical Behavior Cont.’d

List:______Withdrawn, difficulty relating to others

______Preoccupation with food and/or weight

______Talks about home problems

______Talks freely about Drugs,Alcohol Abuse, Sexual activities

_____Bus behavior problems_____Mentions or threatens suicide

_____Has received detention(s)_____Mentions or threatens violence

Comments:Comments:

Physical SymptomsIllicit Activities

_____Deteriorating personal appearance_____Vandalism

_____Sleeping in class_____Involvement in thefts or assaults

_____Frequent cold-like symptoms_____Possession of drugs, alcohol, tobacco, paraphernalia

_____Headaches_____Selling drugs

_____Unsteady on feet_____Carrying a weapon

_____Complaints of nausea or vomiting_____Runaway

_____Smelling of alcohol or tobaccoComments:

_____Glassy, bloodshot eyes

_____Slurred speech

_____Unexplained, frequent physical injuries

_____Hungry

Comments:

Extracurricular Activities

_____Loss of privileges(specify)______

_____Dropped out of______

Current Subjects:Present Grade:Strengths:

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