Student-to-Student concern Intake Form

Your Name: _______________________________        Grade: ____________

Today’s Date: _________________________________________________

Name of person/people you have concerns about: ____________________

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Date that issue(s) occurred: _____________________________________

Describe the events that occurred that caused you concern (be very specific,

including things that were said and done): __________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Name of any witnesses: ________________________________________

____________________________________________________________

Evidence (photos, letters, social media, texts, etc.): __________________

____________________________________________________________

____________________________________________________________

Any other information: _________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

I agree that all of the information on this form is accurate and true to the best of my knowledge.

Signature: ___________________________________________________

Date: ___________________________