An Anonymous Form to Help Us Help Others.
Please categorize your concern:
Select all that apply
Depression and/or Anxiety
Self Harm and/or Suicide
Drugs and/or Alcohol Abuse
Name of the person you are concerned about:
(If you don't know the last name, please type "I don't know")
Which school does the student attend?
Waterloo High School
Waterloo Junior High School
I don't know
Information About Your Concern: Please give as much detailed information about your concern as possible. The more information we have about the situation, the better we are able to help. If you witnessed something happening, please give specific locations (ex: Upstairs D hallway by Ms. Durako's room; the boy's bathroom by the cafeteria, etc).
Describe your concern here:
When did this incident occur?
Or when did you start noticing your concern?
Is there a specific time this is happening?
ie: during passing periods, at lunch, before school, etc...
Name of the violator(s) or person(s) causing harm:
(if a person is causing harm to themselves, you can skip this question)
This form will be submitted anonymously once you hit the "submit" button. However, many times we need additional information in order to help a student. Please know we would not share your name with the person you are concerned about unless you approve it first. We will simply say it was submitted by someone who is concerned about them. If you are willing to provide us with your name, please enter it below. If you would rather remain anonymous, you may skip this question and continue on to submit this form anonymously.
Yes, I am willing to provide additional information or answer additional questions. My name is:
If you were willing to provide your name, the best way to contact you is:
Send me a pass from class during school
Is there anything else we should know?
Please provide any additional comments, concerns, or information you feel necessary for addressing this situation. If you are willing to have us contact you, please provide your contact information below (phone #, email, etc)
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