CONFIDENTIAL

Concern Form Date________

I am concerned about ____________________________Grade _____

Reason for Concern (Check all that apply):

___Drop in academic performance

___Increased absence from school

___Destructive behaviors* against others or self

___ Violence related behaviors:

bullying/ intimidation

written, spoken, or drawn expressions of violence

violent or aggressive actions

other violence problems

___Negative attitudes

___Signs of possible alcohol and other drug use and violence

___Change of friends

___Less extracurricular participation

___Depressed; anxious; frequent mood swings

___Family/living situation (if you suspect abuse, follow MCPS procedures for

reporting. Do NOT use this form for reporting abuse/neglect.)

____Other concerns

Additional Comments (Please describe presenting problems, including your concerns_________________________________

___________________________________________________________________________________________________________________________________________________________________________________

Signature (Optional)________________________________

After completing this form place it in an envelope marked CONFIDENTIAL and place in Ms. Stenger’s mailbox.