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.
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 *
Your Name
Grade of student being referred *
What is your role? *
Never submit passwords through Google Forms.
This form was created inside of Dunmore School District. Report Abuse