Student/School Concern Reporting Form
This is a place for you to communicate concerns you have regarding the safety of yourself and others OR other concerns you don't feel comfortable talking with someone about face-to-face. Please know that these all will be read as soon as we are notified you have submitted the form. We will do our best to address the concern as quickly as possible. If you leave your name, we will follow up with you with any details we can. If you don't leave your name, that is fine but please trust us that we will work to address the problem.
Is this a high school, middle school or both schools concern? *
Your Name (if desired, not required)
Your answer
Description of problem or incident (including names of those involved) *
Your answer
Date of incident (approximately, if known)
MM
/
DD
/
YYYY
Time of incident (approximately, if known)
Time
:
Location of incident
Your answer
Do you feel you need to speak with a counselor or social worker? *
Is there any other information you want to provide us so that we know how best to help you/address your concern OR are there any other needs you have that we can help address?
Your answer
Submit
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