C a r r o l l t o n  -  F a r m e r s   B r a n c h
Confidential Violence Intervention Form
 Please fill out the following information and click on the submit button
(* Indicates required field)
*Student ID#:   
*School/Location:  
*Name of person filling out this form:
*Title:  
*Incident Reported by:  if other
    Reporter Name  
*Date of Incident:
*Time of Incident:
*Directed towards:   Self    Other:

               *Type of Incident:   
                                          Other:  
                                                       ** If written or drawing, we will contact you for a copy.

*Description of incident or exact statement:

  

Contacted parent:

Contacted police:  

If the information above is correct, click submit.


The Counseling Office will contact you as soon as your email is received.

 If you do not hear from us within 1 hour please call 972-968-6500
If you need immediate assistance, please call or page us now.

Thank You