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Hogan Student of Concern Form 
Please fill out this request for support to inform the Counselor, Restorative Practitioner, or Social Worker of areas of concern you have about a scholar's academic, social, emotional or behavioral well-being. This form will better help the counseling department better meet the needs of the scholar.
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Student ID Number  *
Student First and Last Name  *
Grade Level  *
Do any of the following apply to this student:
 *
Urgency Level
 *
Employee Name (Person Completing the Form)
 *
Please follow up with me via:
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Areas of Concern (please click all that apply) 
This will inform us on how to better serve the scholar through interventions and resources. 
Health & Wellness (*** Suicide and Self Harm require immediate consultation with School Counselor do not leave student unattended ***)
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Social Emotional Concerns
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Behavior & Performance
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Additional observations or concerns not listed above
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Please provide a description of your concern using detailed, concise and objective language.
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If applicable, how many times a week are these concerns occurring?
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List 1-2 strengths you have observed in this student:
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For student behavior modification, list the supports or strategies or you have already provided (examples or data may be requested).
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If appropriate, have you contacted the parent/guardian? 
Share a summary of your contact: dates/times/conversation outcome
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Click SUBMIT and this form will be sent electronically to the appropriate designee: Counselor, Restorative Practitioner, or Social Worker. We thank you for exhibiting the core value: Children First. 
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