Bullying and/or Mental Health Concern Form

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Washington District 50 School District is committed to creating a safe, supportive, and positive environment for all students. Counseling support services are available to all students that attend Beverly Manor and John L. Hensey.

This form has been created to help provide an easily accessible and safe means to report bullying and/or mental health concerns 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 non-academic classes.

A tool to identify bullying is the acronym H.O.U.R. It is often bullying when the following are found to be true:
The actions are:
H- Hurtful (physically or emotionally)
O- One-sided (driven by one person and not back and forth interactions)
U- Unfair (treating someone unequal based on their background)
R- Repetitive (happening more than once; repeatedly)

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

-911
-Emergency room

- Dial 988 for the Suicide & Crisis Hotline (formerly National Suicide Prevention Lifeline) or dial 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)
-CARES Hotline 1-800-345-9049

For incidents involving social media, do not hesitate to contact local law enforcement or report users to the Social Media platform if harassment or behaviors that violate appropriate conduct and use policies are being violated.

Thank you for taking the time to complete this form and helping District 50 Schools maintain a safe environment for our students.

Your Name *

Your School *

John L. Hensey

Beverly Manor

Do you wish to be involved in the problem-solving process? *

Yes

Maybe

I am a *

Student

Parent

Staff Member

Other:

Full name of student needing assistance/help *

First Incident: Please describe your concern using as much detail as possible (Part 1). Who was involved and who was a witness? * *

First Incident: Please describe your concern using as much detail as possible (Part 2). Where and when did the first incident take place? Was this interaction face to face or written (either on paper or through social media)? *

Second (or Repeated) Incident: Please describe your concern using as much detail as possible (Part 1). Who was involved and who was a witness? * *

Second Incident: Please describe your concern using as much detail as possible (Part 2). Where and when did this second incident take place? Was this interaction face to face or written (either on paper or through social media)? *

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This form was created inside of District 50 Schools. Report Abuse

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