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Concerns Referral Form
Please fill out when you have a concern regarding possible harm to a child or a concern regarding the safety and well-being of a student, or possible bullying.
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Email *
Person making the report:
Who are you Concerned About? *
What School is the Student in? *
What is your concern? *
There may be times that we may need to follow up with you for further details. However, would you like a counselor to follow up with you regarding how this situation is affecting you? *
Any additional information:
Submit
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