Mental Health Concern Report Form
Metamora Township High School 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. This form will be sent to MTHS counselors and will remain confidential.

Thank you for taking the time to complete this form. MTHS appreciates your help in maintaining a safe environment for our students.

Mental Health Resources
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)
*In cases of emergency, please dial 911

Your name (Optional) Person reporting Mental Health Concern
Your answer
I am a… *
Please list the full name and grade of the person you are concerned for: *
Your answer
Date of submission *
MM
/
DD
/
YYYY
Description of concern: *
Your answer
Submit
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