ARHS Counseling Referral: 2022-2023 
If a crisis, (Suicidal ideation, concern of harming self or others) instead of filling out this form please contact site admin and Mental Health Counselor, Danielle Vielle at Dvielle@dcp.org.

Please complete this form with as much information as possible as it will help the counseling team better understand the student's needs and help us determine the most appropriate supports for the student.

If you have any questions please contact Social worker/counselor: Danielle Vielle, dvielle@dcp.org, 408 673-1119
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Email *
Student name as it appears on Powerschool *
Student grade *
Does the student have an IEP or 504?  *
Are you referring the student/family for school counseling or other community resources? *
Required
If for counseling, what is the reason for Referral? (Please give specific information/observations of behaviors, information shared by student, attendance, data, etc) If a crisis, (Suicidal ideation, concern of harming self or others) please contact site admin and Mental Health Counselor, Danielle Vielle, immediately!
If for Community Resources, check all that apply
Has the student been notified that they are being referred for counseling services?  *
What is the preferred language of the student and family? *
Person Making Referral *
Required
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