Confidential Student Concern Form

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Any individual (school staff member, parent, community member, or student) can confidentially report a student to the Student Well-Being Team about their concern for a student.

Any student information submitted is strictly confidential and a referral may be submitted anonymously. The Student Well-Being Team is comprised of administrators, teachers, counselors, or school psychologist, social worker, and other staff who meet regularly to address concerns and identify possible supports and interventions.

IF THE STUDENT IS AT RISK OF IMMEDIATE HARM OR THIS IS AN EMERGENCY, PLEASE CONTACT A SCHOOL STAFF MEMBER IMMEDIATELY OR CALL 911.

Student Confidential Concern Form

I am concerned about (student's name): *

Reason for concern (Check all that apply): *

Drop in academic performance

Increased absence from school

Destructive behavior against self or others

Negative attitudes

Signs of possible alcohol and other drug use

Change of friends

Depression, anxiety, frequent mood swings

Other

Required

Other concerns/comments

Your name (Optional)

Submit

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