Request edit access
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.
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
Last name of student
Reason for referral
Grade of student being referred
What is your role?
Dunmore School District Faculty/Staff/Administrator/Employee/Coach
Never submit passwords through Google Forms.
This form was created inside of Dunmore School District.