Student Services Help Request
After completing this form, please ask Mrs. Pickett (secretary) for a pass back to class. A member of Student Services will speak with you regarding your issue within 24 hours.
Is this Urgent? (Danger to your self? Danger to others?)
Yes- After completing the form, DO NOT leave. Make sure to talk with a student services member.
What is your first name?
What is your last name?
Date of Incident:
Location of Incident:
My grade/team is:
Check the issue (s) or problem (s) you are currently experiencing.
Left out on purpose
Rumors being spread
My things taken
Being made fun of through electronic means (snapchat, vine, youtube, text messaging, etc.)
Identify the person with whom you are having an issue.
How many times has this happened to you?
4 or more times
Explain the problem or issue that you are experiencing.
What steps have you taken to try and solve the problem/issue?
Ignored the behavior/comment
Told the person to stop the behavior/comment
Told the class teacher about the behavior/comment
Can you name any witnesses who saw or heard the incident you are reporting?
When is your lunch period?
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