Mental Health Concern Form
**IMPORTANT**
Submitting this form does not constitute a traditional student/school counselor confidential conversation. It also does not guarantee immediate services. The form will be processed on regular school days when students and staff are present. For immediate assistance, please see the resources below or visit the counseling office during school hours.

For immediate assistance outside of school hours:
911
Nearest 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

Name of person completing form (optional):
Your answer
Date: *
MM
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YYYY
I am a...: *
Person to contact if additional information is needed (name and contact information of someone who is aware of the situation): *
Your answer
Full name of student needing assistance: *
Your answer
Description of concern: *
Your answer
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