Mental Health Concern Report Form
Thank you for taking the time to complete this form. Fieldcrest appreciates your help in maintaining a safe environment for our students.

*In cases of emergency, please dial 911. Such cases would include matters of life or death, or those which require IMMEDIATE intervention and cannot wait a few hours or until tomorrow.

Fieldcrest Community Unit School District #6  is committed to creating a safe and supportive learning environment for all students.  This form has been created to help provide a safe means of reporting a concern for a student’s mental health and well-being.  The form is designed to remain anonymous and encourage reports of concerns for a student’s mental health so appropriate action can be taken. When completed, this form will be sent to Fieldcrest administration immediately, and will remain confidential except for required action to address the concern(s) indicated.

Other Mental Health Resources which are available:
National Suicide Lifeline: 1-800-273-8255
24/7/365 Crisis Hotline: 1-775-784-8090
Crisis Text Line: Text the word LISTEN to 741-741
Child Abuse Hotline: 1-800-15-ABUSE (22873)
Center for Prevention of Abuse (sexual assault services): 1-800-559-SAFE (7233)
Substance Abuse and Mental Health Services Administration (referral service): 1-800-662-HELP (4357)

Results from this form will sent immediately to the above noted recipients. There will be at least one designated reader every day during the school year.
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Your name (optional)
I am a... *
Name(s) of student(s) of concern *
Grade level of student *
Date of report *
Description of concerns *
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