Counselor Request Form for Parents & Adults
Please fill out this form and use it to let us know that you feel that your student needs to speak with a counselor and a member of our team will be in touch to set up a Google Meet appointment.  If you submit this after school hours, someone will reach out to you during the next school day.

IF THIS IS AN EMERGENCY (i.e. Someone is in danger of hurting themselves or other people):

- During the school day: Call the office directly at 570-271-3268 ext.3800 and ask to speak with an administrator or counselor...let them know it is an emergency.

- Outside of school hours: Report on Safe to Say (https://www.safe2saypa.org/tip/), tell a trusted adult, and call 911 if someone is in immediate danger.  If you need immediate help can also call the Crisis TAPLine at 1-800-288-9016 or text "HELLO" to 741741 to speak to a trained counselor.
Sign in to Google to save your progress. Learn more
Please click on the calendar icon below and click on today's date (highlighted in blue). *
MM
/
DD
/
YYYY
Student's First & Last Name *
Student's Grade *
Name of Parent/Adult Submitting Referral: *
Parent/Adult Email Address: *
Parent/Adult Phone Number: *
Items that you would like a counselor to discuss with your student? *
Can you briefly describe the situation that you are seeking help about?  If you selected "Potential Bullying" for the previous question, can you let us know when and where the incident happened and the names of anyone else who was involved?   *
***This information is considered confidential and all reasonable efforts will be made to protect students who wish for their concerns to stay anonymous***
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Danville Area School District. Report Abuse
Google Forms