Student Concern Form:

Student Concern Form
1.
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I am concerned about the following student:

2.

Is this person a St. Croix Central Middle School Student?

Is this person a St. Croix Central Middle School Student?

3.

If the student does not attend St. Croix Central Middle School, how do you you know this student? If you know the school he or she attends, please list the name.

4.
*

This is what I saw, heard, I am concerned about:

5.
*

Have you ever discussed your concerns about this person with a parent, teacher, counselor, or other trustworthy adult?

Have you ever discussed your concerns about this person with a parent, teacher, counselor, or other trustworthy adult?

 
6.

If possible, please provide the name of that person:

7.

If you would like to discuss your concerns about a student or situation you witnessed, please provide your name. THIS IS OPTIONAL. You are not required to give your name if you wish this report to be anonymous. If you do provide your name, the school counselor (Kat) will be in contact with you within the next school day after the report is made. If you are a parent reporting and would like the counselor to contact you, please leave a number where you can be reached.

I am not a Robot

  

St. Croix Central Middle School • 1295 Vine Street, Hammond, WI 54015 • 715-796-2256 • Fax: 715-796-2460
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