Concern for Others Form

Greenville College Counseling Services

Concern for Others Report

Note: Information on this form is ABSOLUTELY CONFIDENTIAL

Your Name (optional):
Name of the student you are concerned about:

Please indicate what you have observed or concern you have about this student (Check all that apply):

Tearful/Crying	Mood Swings	Hostile
Poor Grooming	Inappropriate Touching	Fidgety
Social Isolation	Intimidating to Others	Threatening Others
Bruising	Frequent Absences	Argumentative
Suspicious	Poor Performance	Stalking
Slurring Words	Abusive Language	Noncomplient
Avoiding Others	Seeing or Hearing Things	Burns or Cuts
Odor	Freqent Injuries	Emotionless
Fighting	Extremely Thin	Over Eats
Physically Abusive	Does Not Attend Chapel	Other (note below)

Other significant information:

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