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Care & Concern Form
DO NOT fill out this form for any suspected abuse or self harm, crisis situation, or any matter that needs immediate attention. Dial 0 for intimidate assistance from your Counselor and Administrator.

DO fill out this form to alert Counseling of developing student concerns.

Some examples of why you would complete this form:

- Academic performance has declined
- A student's demeanor has changed
- A student has been absent more often
-A student seems to have a lack of motivation in class/engagement level has changed

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Staff member referring the student *
Student Name (first and last) *
Student Grade Level *
Student Team
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Briefly describe concern and any interventions you have already tried: *
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