Worried About Someone?

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Please complete this form if you are Worried About Someone and/or if you think that they may need to speak to a counselor.

During School Hours: If you or someone you know is having thoughts of suicide or thoughts to hurt others, please report to the counseling center or tell a trusted adult immediately.

After School Hours: If you or someone you know is having thoughts of suicide or thoughts to hurt others, please tell a trusted adult, call or text the Suicide Prevention Lifeline at 988, or contact 911.

If a student is in danger of hurting themselves or others, please contact the counseling center or tell a trusted adult immediately. Do not wait....See something, Say Something, Do Something!

Email *

Date: *

YYYY

Your name (First and Last): *

Name of student you are concerned about (First and Last): *

Do you wish to remain anonymous when the student is contacted? *

Yes

Building: *

Grade (if known): *

Did the student indicate any threat of or potential harm to self or harm to others? *

Yes

Concerns (check all that apply): *

Written or verbal statements regarding suicide or death

Self-harm and/or ideations

Abuse/neglect suspected or reported

Changes in weight or eating habits

Concerning social media post

Made threats against self and/or others

Misconduct or inappropriateness

Use of substances and/or alcohol

Other:

Required

Summary of Concern:

Submit

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This form was created inside of De Soto Public School District #73. Report Abuse

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