Bullying and Mental Health Concern Form
Washington Grade School District is committed to creating a safe, supportive, and positive environment. Support services are available to students that attend WMS and LGS.

This form has been created to help provide a safe means to report bullying and/or a mental health concern to school personnel. We encourage everyone (victims and bystanders) to report their observations. All forms will be processed on regular school days when students and staff are present.

Bullying is defined as physical or verbal conduct, by one or more students, which serves to harass, demean, humiliate, abuse, victimize, deny, or exclude one or more students from the pursuit of participation in, and/or enjoyment of any program or activity, including academic and nonacademic classes.

For immediate assistance outside of school hours, please see the resources below:

-911
-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)

Thank you for taking the time to complete this form and helping WGSD maintain a safe environment.

Your name
Your answer
Date of Report *
MM
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DD
/
YYYY
You are a *
Full name of student needing assistance *
Your answer
Please describe your concern using as much detail as possible (Part 1). Who was involved and who was a witness? *
Your answer
Please describe your concern using as much detail as possible (Part 2). What happened/What was said? *
Your answer
Please describe your concern using as much detail as possible (Part 3). Where did the incident(s) take place? *
Your answer
Please describe your concern using as much detail as possible (Part 4). When did the incident(s) take place? *
Your answer
Please describe your concern using as much detail as possible (Part 5). How did the incident(s) take place (face to face, written words, social media, etc.)? *
Your answer
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