Because You Care Form
Please fill out the below with as much information as possible. You are always encouraged to discuss any student concerns with the Administration, Teachers, Counselors, or School Resource Officer. Please feel free to contact us at 815-844-6113.
* Required
What type of student concern are you reporting?
Check all that apply -
Bullying/Harrassing
Concern over a student's emotional well-being (i.e. thoughts of suicide or self-harm)
Domestic abuse
Sexual abuse
Drug/Alcohol abuse
Other:
Clear selection
Name(s) of person(s) of whom you are concerned.
*
Your answer
Please describe your concerns. If a specific incident has occurred, please describe the incident in detail.
Your answer
Date of Incident
MM
/
DD
/
YYYY
Time of Incident
Time
:
AM
PM
Room/Location of Incident
Your answer
Name(s) of person(s) that may be doing the bullying/harassing, or contributing to the concerns mentioned above.
Your answer
Name(s) of person(s) who witnessed incident or share concerns.
Your answer
Inappropriate behaviors observed:
Check all that apply.
Name Calling
Stalking
Inappropriate Gesture
Threatening
Taunting/Ridiculing
Inappropriate Touching
Cyberbulling
Demeaning Comments
Damaging Property
Shoving/Pushing
Hitting/Kicking
Flashing a Weapon
Intimidation/Extortion
Other
Behavioral/Social/Emotional Concerns
Check all that apply.
Anxiety/Stress
Extreme Aggression
Restricted Eating/Binge Eating
Depression/Expressions of hopelessness, fear, or worthlessness
Grief and/or Loss
Severe Perfectionism
Acts motivated by hatred or discrimination
Inappropriate Emotional Outburst
Physical/Sexual Abuse/Domestic Violence
Misuse of medication
Alcohol/Drugs
Self-Harm behaviors (Cutting, burning, etc)
Paranoia/delusions
Physical evidence available
Check all that apply.
Notes
e-mail
web sites (Facebook, etc.)
Text messages
Video/Audiotape
Other
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