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Student of Concern Form Template

Empower teachers to address student concerns effectively

When you notice unusual behavior in the classroom, addressing it promptly can make all the difference. This Student of Concern Form Template helps educators clearly document and communicate issues regarding student behavior, leading to timely interventions. By using this streamlined form, you can ensure consistent communication, maintain accurate records, and facilitate collaboration among school staff to support students in need. Create a clear path for positive change with this easy-to-use template.

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Your full name
Your role/relationship to the student
Please Specify:
Department or unit
Your email
Your phone
Preferred contact method
Email
Phone
Either email or phone
Text/SMS
No follow-up needed
Student full name
Student ID or number
Student email
Student phone
Program or major
Year/level
First year
Second year
Third year
Fourth year
Graduate
Postgraduate/Doctoral
Unknown
Other
Please Specify:
Residence status
On-campus housing
Off-campus housing
Commuter
Unknown/Not applicable
Date of concern or when first noticed
Location of concern or context
Primary concern category
How urgent is this concern in your view?
Low urgency
Moderate urgency
High urgency
Immediate emergency
Unsure
Is anyone at immediate risk of harm right now?
Yes
No
Unsure
If there was immediate risk, were emergency services contacted?
Yes
No
Not applicable
Have you discussed this concern with the student?
Yes
No
Not applicable
Behaviors or indicators observed (select all that apply)
Please Specify:
How often have you observed this concern?
Never
Rarely
Sometimes
Often
Always
Perceived impact on student wellbeing or academics
No impact
Minor impact
Moderate impact
Significant impact
Severe impact
Describe what happened or what you observed
Actions taken so far
Spoke with the student
Emailed the student
Referred to counseling or mental health services
Referred to academic advising or tutoring
Notified supervisor/Dean
Contacted campus safety
Provided resources or accommodations
No action taken
Other
Please Specify:
Has the student expressed intent to harm themselves?
Yes
No
Unsure
Prefer not to say
Has the student expressed intent to harm others?
Yes
No
Unsure
Is there indication of access to means or a specific plan?
Yes
No
Unsure
Not applicable
Additional risk details (if any)
How likely is it that the situation will escalate in the next 30 days?
0 Not at all likely
1
2
3
4
5 Extremely likely
What support would you like us to provide?
Please Specify:
Preferred follow-up timeframe
Within 24 hours
Within 2-3 business days
Within one week
No follow-up needed
Unsure
Best times or days to contact you
May we share the information in this report with relevant campus support offices?
Yes
No
Your signature
Submission date
I affirm the information provided is accurate to the best of my knowledge
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
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paper art illustration featuring a student form template with educational icons and design elements for FormCreatorAI article

When to use this form

Use this form when a student shows patterns that need coordinated support, such as repeated missing work, a sudden drop in grades, withdrawal from peers, disruptive outbursts, threats, or chronic tardiness. It helps you capture what happened, who saw it, and why it matters so your team can act fast. Teachers, counselors, deans, and RTI/MTSS teams benefit from a single, clear record that routes to the right people. To add context, attach notes captured in the Teacher observation form and summarize trends with the Student progress report form. The result is a documented history that supports timely outreach, family contact, safety planning, or academic interventions.

Must Ask Student of Concern Questions

  1. What specific concern are you reporting, and when and where did it occur?

    This establishes the facts and context so your team can assess urgency and risk. Dates and locations make patterns visible and reduce hearsay.

  2. How often has this issue occurred, and over what timeframe?

    Frequency and duration show severity and whether the issue is escalating. If you have observation logs, reference the Student observation form for consistent data.

  3. What impact is this having on the student's learning, safety, or peers?

    Impact clarifies priority and the level of support needed. It also aligns your request with school safety and learning goals.

  4. What strategies or interventions have you tried, and what were the results?

    Knowing what you tried prevents duplicate efforts and informs next steps. If behavior is complex, your notes can support a Functional behavior assessment form.

  5. Who has been informed so far (guardian, counselor, admin), and what was their response?

    Routing is faster when we know who is involved and what was shared. This supports transparency with families and helps meet policy requirements.

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