Bully Box
Who was involved with the situation/behavior (all persons)?
What is the bullying situation or behavior that happened?
Where did the situation or behavior occur?
When did the situation or behavior occur?
Before School
During School
After School
Outside of School
Other, please specify
Have you talked to anyone else about what has happened?
Have you talked to anyone else about what has happened?
Yes
No
Is there anything else that you would like me to know?
Person submitting the referral (optional - your name will only be used if we need additional information):