Threat Assessment Initial Referral Form

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Centralia City Schools District #135

Name of Individual Completing Form (optional)

Position of Individual Completing Form *

School Employee

Student

Parent/Community Member

Name of Student of Concern *

School where student attends *

Schiller

Jordan

Central Middle School

Centralia Junior High School

Pre K Center

Required

Type of Threat *

Verbal Threat

Written Threat

Email/Social Media Threat

Harmful Behavior

Violent Behavior

Threatening Behavior

Prohibited Behaviors *

Use/Possession of a Weapon

Homicidal Ideation

Suicidal Ideation

Assault

Fighting

Self Harm

Dating Violence

Sexual Assault/Harassment

Stalking

Bullying

Cyberbullying

Required

Exact wording and nature of the threat *

Intended Targets *

Submit

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