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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:
Your answer
First and Last name of the Bully:
Your answer
Where did this situation/behavior occur?
Your answer
When did this situation/behavior occur?
Required
Type of Bullying (select all that apply):
Required
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.).
Your answer
Please list all witness, if any, to this event?
Your answer
Is there anything else you would like me to know?
Your answer
Are you comfortable including your name? (It will be kept confidential and only seen our counselors
Your answer
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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