Student Assistance Program - Parent/Guardian Consent - NESD

Your child has been referred to the Student Assistance Program (SAP). This voluntary program is available to offer supportive services to students experiencing academic, behavioral, and/or emotional difficulties that may pose barriers to school success.

Students can be referred to the Student Assistance Program by parents/guardians, school personnel, peers or as a self-referral. The SAP team is composed of trained teachers, administrators, school counselors and a mental health and/or drug & alcohol counsultant(s).

Our goal is to work with you and to offer support and recommendations for your child. Where obstacles arise beyond the scope of the school, the SAP team can provide information so that families may access additional community resources where needed.

Please complete the bottom portion of this form and click submit.
I give my consent for the following for my child: (Child's name) I give my consent for the following for my child: (Child's name) First Last
Child's School Building
Please select all that apply:

Please select all that apply: To proceed with the Student Assistance Program and permit the SAP team to discuss my child. To meet with a Pyramid Drug and Alcohol Counselor for an assessment and subsequent counseling for purposes of prevention and/or intervention. To meet with a North East School District Mental Health Specialist for assessment and therapeutic support. I do not give permission to proceed forward with the Student Assistance Program.
Parent/Guardian Name: Parent/Guardian Name: First Last
Parent(s)/Guardian Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date: Date: / MM / DD YYYY
Best number to contact you at: Best number to contact you at: - ### - ### ####
Email Address: