High School Concerned Student form
This referral is for students who wish to refer other peers. Students have the ability to leave their names or remain anonymous.
First & Last Name of Person Referring Student
*
First Name
Last Name
Do you wish to remain anonymous(unknown reporter)?
*
Yes
No
Student Name
*
First Name
Last Name
Teacher Name
*
First Name
Last Name
Grade
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Describe Your Concerns (Please be specific describing the nature of the situation):
*
Behaviour and characteristics of concern
*
Has not been attending class
Has been consistently inattentive and/or asleep in class
Has been verbally hostile and/or aggressive to teacher and or classmates
Displays unusual degree of anxiety interpersonal or in relation to academic expectations
Displays excessive anger and acts out aggressively
Demeanor has changed from outgoing, involved and responsive to withdrawn and avoidant
Has acknowledged that he/she is depressed and overwhelmed
Has acknowledged that he/she is extremely anxious and overwhelmed
Is being bullied
Has threatened self-harm
Has made vague statements about wanting to be dead
Has attempted self-harm
Other students have expressed alarm and concern about this student
Other
Additional information regarding concern(s)
*
Additional Comments
*
On a scale from 1 to 5, how serious (immediate) is this concern
*
Less Serious
1
2
3
4
Very Serious
5
1 is Less Serious, 5 is Very Serious
Submit
Should be Empty: