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Dunmore High School (9-12) SAP Referral Form 2020-21
The Student Assistance Program is a state mandated program to identify and assist students. Students are referred regarding problem behaviors such as a decline in grades, suspected drug use or behaviors that inhibit learning. Anyone may make a referral. Referrals can be made anonymously except in the case of teachers or staff. It is expected in their professional capacity that teachers and staff identify themselves when making a referral. This information is confidential and not shared with the student.
* Required
IMPORTANT **PLEASE READ**
Please note that if you have concerns regarding the immediate welfare of a child during the school day, such as suicidal ideations, self harm, or possession of weapons or drugs, discontinue this process and immediately contact a counselor or administrator. For similar concerns outside of school hours, please call 911.
First name of student
*
Your answer
Last name of student
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Your answer
Reason for referral
*
Your answer
Your Name
Your answer
Grade of student being referred
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9
10
11
12
Required
What is your role?
*
Dunmore School District Faculty/Staff/Administrator/Employee/Coach
Parent
Community Member
Student
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