Dansville Student Concern Form

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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.

Required

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

Social withdrawal/isolation

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

Other:

Required

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 *

Yes

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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