Dansville Student Concern Form
Please complete the information below if you have a concern for a student's well being.
This form will only be seen on School Days from 7:30 AM – 3:00 PM. If it is after 3:00, a weekend or vacation day, please call 911 with your concern and follow up with your counselor during the next school day.
I understand the statement above.
I am concerned about: (First & Last Name)
I am concerned about the student for the following issues (please check all that apply)
Change in personality
Feelings of guilt
Ideas of self-punishment
Crying spells or inability to cry
Neglect of personal appearance
Unusual rebellious behavior
Lack of investment in the future or absence of future goals
Verbal statements of wishing to die or death
Verbal statements of worthlessness, sense of failure, or isolation
Preoccupation with unpleasant thoughts (such as death or dying)
Does not seem to care about anything
Seems to feel hopeless or helpless
Feeling like a burden to others
Loss of appetite or weight loss
Use of drugs or alcohol
Very critical of self
Giving away prized possessions
None of the above
Additional details explaining the reason that I am concerned (please be as specific as possible):
I would like to speak with an adult about this as soon as possible during the next school day
I understand that if I am completing this form after school hours and I believe that the individual is in immediate danger, I will call 911 right away.
Yes, I understand
My name is (will be kept confidential)
For safety reasons, in order to make sure that someone addressed your concern right away, this form will be submitted to the High School Counselors for their review and action
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