School Tipline / Counseling Referral Form
When should you complete this form? If you or somebody you know needs help. This can be:

- Bullying, harassment, intimidation,
- academic problems (struggling academically, note taking, organization, time management, test taking etc.),
- personal problems ( trouble at home, parents divorce, grief/loss, stress, social skills, trouble with friends, self-esteem, self-harm etc.)
- or if you want to talk about high school planning and post-secondary options.

You can submit this form anonymously. A link to this form is also on our website www.thegroveschool.org under "Counseling"

PLEASE NOTE:

YOUR EMAIL IS NOT BEING RECORDED WHEN YOU SUBMIT THIS FORM.

IF YOU OR SOMEONE YOU KNOW NEEDS IMMEDIATE ASSISTANCE, TALK TO ANKE IN PERSON IMMEDIATELY or call 911.

Are you a
Student that needs assistance: *
Your answer
Your name (If you want this referral to be anonymous, leave this question blank):
Your answer
Areas of Concern *
Explain your concerns. Be as specific as possible. Who? Where? When? What? *
Your answer
Submit
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