Elementary Student Assistance Program

Online Referral Form

Benton Area Student Assistance Team Referral Form
This is a Confidential Form

Student(s) being referred:
Date of referral:

Name of person making the referral:
Leave blank if you wish to remain anonymous

Reason(s) for concern:

Thank you for your consideration and your time! 

What is the Student Assistance Program (SAP)?

The Benton Area Student Assistance Program is designed to assist students, parents, and school personnel with identifying issues or concerns.  These issues may include: alcohol, drugs, or mental health concerns which pose barriers to a student's learning and school success.

Our Student Assistance Team composed of professionally trained individual subject teachers, counselors, principal, and school nurse will not serve as a treatment program at school.  Instead, the team will guide the student and family through a systematic process to receive help.  The team will use effective professional techniques and utilize school resources when appropriate.

The team will gather data from teachers when a student is referred.  If the problem is beyond the scope of our school resources, the team assists the family and the student with information for accessing services within the community.

Do You See Your Child Showing Any of These Behaviors?
  • Withdrawing from family, friends, and/or school
  • Changing friends; no longer spends time with old friends
  • Unexplained physical injuries
  • Talking about suicide
  • Depressed
  • Defying authority, both at home and at school
  • Acting aggressively
  • Lying
  • Needing money without an explanation
  • Sudden drop in grades
  • Experimenting with drugs or alcohol
If your child is having trouble in or out of school, we can help.  There may be times when you just don't know how to help your child.  That's okay; someone else may know how to help.
What if Someone Has Already Referred My Child to the Program?

First, know that your child was referred because someone is concerned about observable changes they are seeing in your child.  Perhaps a teacher or friend has noticed changes in behavior and habits that you may or may not have noticed at home.

The SAP Team will request that you sign a permission form for your child to become involved in the program.  Once you sign the form, the SAP Team will begin to work with you and your child.  If you feel you need more information before making a decision, please let your SAP Team know.  If you do not sign the permission form, the SAP Team cannot work with your child.

Participation is voluntary.

Resources for Assistance
In the School:
Student Assistance Team Members:
  • Ms. Jen Pierce (Guidance Counselor)
  • Mrs. Krista Weaver (School Nurse)
  • Ms. Tammy Miller (Social Worker)

In the Community:
  • CMSU Main Office: (Mental Health/Drug & Alcohol Services)
  • Center for Substance Abuse: (Treatment Hotline)
  • Childline: (Child Abuse Hotline)
  • TAPLINE: (Mental Health Crisis Hotline)
  • Alcoholics Anonymous: 570-654-0488
  • Narcotics Anonymous: 570-988-7177
  • Guide to Heroin Addiction
  • Guide to Heroin Rehab

All referrals are kept CONFIDENTIAL.  Referrals can also be submitted through paper copies and placed in the referral boxes located in the Library and Locker Rooms.
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