Bullying and/or Mental Health Concern Form
Washington District 50 School District is committed to creating a safe, supportive, and positive environment for all students. Counseling support services are available to all students that attend Beverly Manor and John L. Hensey.

This form has been created to help provide an easily accessible and safe means to report bullying and/or mental health concerns to school personnel. We encourage everyone (victims and bystanders) to report their observations. All forms will be processed on regular school days when students and staff are present.

Bullying is defined as physical or verbal conduct, by one or more students, which serves to harass, demean, humiliate, abuse, victimize, deny, or exclude one or more students from the pursuit of participation in, and/or enjoyment of any program or activity, including academic and non-academic classes.

A tool to identify bullying is the acronym H.O.U.R. It is often bullying when the following are found to be true:
The actions are:
H- Hurtful (physically or emotionally)
O- One-sided (driven by one person and not back and forth interactions)
U- Unfair (treating someone unequal based on their background)
R- Repetitive (happening more than once; repeatedly)

For immediate assistance outside of school hours, please see the resources below:

-911
-Emergency room
-National Suicide Prevention Lifeline 1-800-273-8255 (www.suicidepreventionlifeline.org)
-Text HOME to 741741 from anywhere in the US, anytime, about any type of crisis.
-Emergency Response Services (ERS) 309-347-1148
-Partnership for a Healthy Community (www.healthyhoi.com/emergency)
-211 (www.211hoi.org)
-CARES Hotline 1-800-345-9049

For incidents involving social media, do not hesitate to contact local law enforcement or report users to the Social Media platform if harassment or behaviors that violate appropriate conduct and use policies are being violated.

Thank you for taking the time to complete this form and helping District 50 Schools maintain a safe environment for our students.

Your Name *
Your answer
Your School *
Do you wish to be involved or anonymous in the problem solving process? *
You are a *
Full name of student needing assistance/help *
Your answer
Please describe your concern using as much detail as possible (Part 1). Who was involved and who was a witness? * *
Your answer
Please describe your concern using as much detail as possible (Part 2). What happened/What was said? * *
Your answer
Please describe your concern using as much detail as possible (Part 3). Where did the incident(s) take place? * *
Your answer
Please describe your concern using as much detail as possible (Part 4). When did the incident(s) take place? * *
Your answer
Please describe your concern using as much detail as possible (Part 5). How did the incident(s) take place (face to face, written words, social media, etc.)? * *
Your answer
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