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South Pointe Middle School online "Bully Box" Referral Form
This form is completely anonymous, and your responses go to our counselors. If you would like to receive follow-up, you can include your name at the bottom of the form.
First and Last name of person being bullied:
First and Last name of the Bully:
Where did this situation/behavior occur?
When did this situation/behavior occur?
OutSide of School
Type of Bullying (select all that apply):
Physical (hitting, kicking, slapping, getting another person to hit or harm the victim, or other physical aggression)
Verbal (Teasing, nam calling, put-downs, or other verbal behavior that would hurt others' feelings or make them feel bad)
Emotional/Exclusion (starting rumors, telling others not to be friends with someone, harassment, intimidation, or other actions that would cause someone to be without friends)
Cyber Bullying (Using n electronic device to engage in any previously mentioned bullying)
Describe the events. What did the alleged offender do or say? Please describe with as much detail as possible. List any evidence, if any (letters, photos, notes, etc.).
Please list all witness, if any, to this event?
Is there anything else you would like me to know?
Are you comfortable including your name? (It will be kept confidential and only seen our counselors
NOTE: submitting false or inaccurate information is considered lying
NOTE: submitting false or inaccurate information is considered lying.
This form will be electronically sent to the Office. An administrator or counselor are the only people who will see what is submitted. Please feel free to print this form out and submit it to our Middle School Bully Box located in the library.
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This form was created inside of Walnut Valley USD.