THREAT NOTIFICATION
TOP PORTION OF FROM TO BE COMPLETED BY PERSON RECEIVING/PERCEIVING/OVERHEARING THE THREAT.
TAKE TO ADMINISTRATOR (OR COUNSELOR IF ADMINISTRATOR UNAVAILABLE) IMMEDIATELY WITH STUDENT.
DATE/TIME: ______________ PERSON REPORTING: __________________________ TITLE: _____________________
REPORTING TO: ___________________________________ CAMPUS: ____________________________________
(Principal, Assistant Principal, Director, etc.)
STUDENT MAKING THREAT________________________________ GRADE: ____________
THREAT MADE TO HARM: _____ SELF _____ STUDENT _____ FACULTY _____ OTHERS
WAS THERE A GESTURE ACCOMPANYING THE THREAT? ________________________________________________
THREAT MADE ON SCHOOL PROPERTY? _____ YES _____ NO
IF NOT, WHERE DID THREAT OCCUR?_______________________________________________________________
THIS PORTION TO BE COMPLETED BY REPORTER, OR ADMINISTRATOR/COUNSELOR DURING AN INTERVIEW WITH THE REPORTER LISTED ABOVE
ATTACH ANY PAPER DOCUMENTS OR OTHER DOCUMENTATION ASSOCIATED THE THREAT MADE.
1. What was said and to whom?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
2. What was written and to whom?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
3. What was done?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
4. When and where did this occur?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
5. Who else observed this behavior?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
6. Did the student say why he or she acted as they did?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
By signing below, I acknowledge the above statements are an accurate account of what occurred.
Reporter’s Signature_________________________________________
Administrator or School Counselor starts the Threat Assessment/Inquiry Process
Date_____________
PAGE 1
Student Safety Protocol-Threat to OTHERS
(Page 1 to be completed by School Counselor upon receipt of the Threat Notification from Administrator)
Purpose:




To provide analysis of potentially threatening situations
To provide the basis for deciding appropriate referral for services/interventions
To prevent school violence
To diminish the chance of any student or staff member being harmed
Threat Assessment/Inquiry Team:
Administrator: ______________________________________ Campus: ______________
Counselor: _________________________________________________________________________________________
Therapist (if needed):________________________________________________________________________________
Other: ____________________________________________________________________________________________
Resource Office (if threat to someone else):______________________________________________________________
Student Making Threat: ___________________________________________ SSN: ____________________________
Last
First
MI
Age: _____
DOB: _____________
Grade: _______
Race: _______
Gender: ______ M ______F
Guardian: ___________________________________________ Relationship: __________________________________
Address: __________________________________________________________________________________________
Home Phone: __________________________________ Cell phone: ___________________________________
Emergency Contact: ____________________________ Phone Number: ________________________________
Please mark any of the following current or past information that is relevant to this student (indicate C or P):
__Family Conflict
__Poor Academic Performance
__ Poor Social Skills
__ Relationship Conflict
__ Relationship Conflict
__ History of Harassing Others
__ History of Being Harassed
__ Violence Towards Self
__ Violence Towards Others
__ Victim of Violence/Bullying
__ Attitudes about Violence
__ Criminal Behavior
__ Mental Health Disorder
__ Substance Abuse History
__ Access to/Use of Weapons
__ Recent Loss
__ Suicidal Ideation/Gesture
__ History of Grievances/Grudges
__ History of Abuse/Neglect
__ Homicidal Ideation
__ Court Involvement
__ Special Education
__ Unstable Home Environ.
__ Poor Family Support
__ Perception of being treated
__ Recent Downward Progression
__Difficulty coping w/stress
__ Frequent Discipline
unfairly
of functioning
referrals
OTHER:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
**Adapted from United States Secret Service and United States Department of Education, Threat Assessment in Schools: A guide to Managing
Threatening Situations and to Creating Safe School Climates. Washington D.C.: 2004
PAGE 2
THREAT ASSESSMENT/INQUIRY – CONT.
Section 1 to be completed by School Counselor: Section 2-11 to be completed by Licensed mental Health Professional. If School
Licensed Mental Health Professional is unavailable, the School Counselor and Administrator complete Sections 2-11 together and
contact a mobile assessor (after gaining parental permission for outside assessment).
ALL yes answers require narrative comment.
**Adapted from United States Secret Service and United States Department of Education, Threat Assessment in Schools: A guide to Managing
Threatening Situations and to Creating Safe School Climates. Washington D.C.: 2004
1.
MOTIVES AND GOALS:
a.
b.
Has the student failed to express what motivated him/her to make the statement or take the actions that caused him/her to come
to the attention of the district administration?
____ yes
____ no
Does the situation or circumstance that led to these statements or actions still exist?
_____ yes ___ no
c. Does the student have a major grievance or grudge?
If yes, against whom?____________________________
____yes____no
d.
Has the student failed to make efforts to resolve the problem?
_____yes____no
e.
Does the potential attacker fail to see any alternatives to remedy the problem?
____ yes ____ no
Note to School Counselor: If ALL of the above answers are “no” skip to the bottom of Page 4. TRANSIENT THREAT. Otherwise
contact a Licensed Mental health Professional to assess further.
2.
3.
4.
5.
STUDENT INTEREST IN ANY OF THE FOLLOWING:
School attacks or attackers, weapons (including recent acquisition of any relevant weapon) incidents of mass violence
(terrorism, workplace violence, school violence, mass murders)
_____yes _____no
b.
Has he/she mentioned Columbine, Santana, Jonesboro, Sandy Hook, etc.?
_____ yes ____no
COMMUNICATION SUGGESTING IDEAS OR INTENT TO ATTACK:
a.
Has the student communicated to someone else (targets, friends, other students, teachers, family, others) or written a diary,
journal, or web site concerning his/her ideas and or intentions.
_____ yes _____no
b.
Have friends been alerted or “warned away”?
_____yes _____no
HISTORY OF ATTAACK RELATED BEHAVIORS:
a.
Developing an attack idea or plan
_____yes ____no
b.
Making efforts to acquire or practice with weapons
_____ yes ____no
c.
Casing or checking out possible sites and areas for an attack
______yes ____no
d.
Rehearsing attacks or ambushes
_____yes _____no
e.
Other:___________________________________________________________________________________________________
CONSISTENCY OF STUDENT ACTIONS:
a.
6.
a.
Does information from the collateral interviews and from the student’s own behavior dispute what he/she says is going on?
_____yes _____no
CAPACITY OF STUDENT TO CARRY OUT AN ACT OF TARGETED VIOLENCE (toward self or others)
a.
Does the student’s thinking and behavior appear organized?
_____yes _____no
b.
Is there a plan in place?
_____yes _____no
c.
7.
8.
9.
Does the student have the means (i.e. access to a weapon to carry out an attack)?
_____yes _____no
PAGE 3
STUDENT EMOTIONAL STATE: IS THE STUDENT EXPERIENCING HOPELESSNESS, DESPERATION AND/OR DESPAIR?
a.
Has the student experienced a recent failure, loss and/or loss of status?
_____yes _____no
b.
Is the student known to be having difficulty coping with a stressful event?
_____yes _____no
c.
Is the student now, or has the student ever been, suicidal or “accident-prone”?
_____yes _____no
d.
Has the student engaged in behavior that suggests that he or she has considered ending their life?
_____yes _____no
TRUSTING RELATIONSHIPS:
a.
Does the student lack at least one relationship with an adult where the student feels that he or she can confide in the adult and
believes that the adult will listen without judging or jumping to conclusions?
_____yes _____no
b.
Is the student emotionally disconnected from other students?
c.
Has the student previously come to someone’s attention or raised concern in a way that suggests he or she needs interventions
or supportive services?
_____yes _____no
CIRCUMSTANCES THAT AFFECT THE LIKELIHOOD OF AN ATTACK:
a. Are there factors in the student’s life and/or environment that might increase the likelihood that the student will
attempt to mount an attack at school?
_____yes _____no
b.
Are those who know the student concerned about a specific target?
_____yes _____no
c.
Have those who know the student witnessed recent changes or escalations in mood or behavior?
_____yes _____no
10. CIRCMSTANCES THAT AFFECT THE LIKELIHOOD OF AN ATTACK:
a.
Are there factors in the student’s life and/or environment that might increase the likelihood that the student will attempt to
mount an attack at school?
____yes _____no
b.
What is the response of other persons who know about the student’s ideas or plan to mount an attack? (Do those who know
about the student’s ideas actively discourage the student from acting violently, encourage the student to attack, deny the
possibility of violence, passively collude with an attack, etc.) ______________________________________________________
_______________________________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________________________________________________
11. STUDENT’S BELIFE REGARDING VIOLENCE:
a. Does the setting around the student (friends, fellow students, parents, teachers, adults) explicitly or implicitly support or
endorse violence as a way of resolving problems or disputes?
b.
Has the student been “dared” by others to engage in an act of violence?
_____yes _____no
_____yes _____no
Page 4
EXTENDED ASSESSMENT/INQUIRY RESULTS
To be completed only after the above information has been gathered and the student interviewed.
CATEGORY OF THREAT:
_____Transient Threat-Rhetorical remarks, not genuine expressions of intent to harm, At worst, expresses temporary
feelings of anger or frustration. These can usually be resolved on the scene or in the office. After resolution, the threat no longer
exists. Transient threats usually end with an apology or clarification. When in doubt, threat as a substantive threat and involve a
licensed mental health professional.
____________________________________________________
School Counselor Signature
Date
_____Substantive Threat-Expressed intent to physically injure someone beyond the immediate situation. There is at
least some risk the student will carry out the thread. Requires protective actions; including warning intended victims and parents.
May include legal violations and the need for police consultation/involvement.
_____SERIOUS Substantive Threat – Threats of assaulting someone
_____VERY SERIOUS Substantive Threat – Threats to kill, rape or inflict very serious injury to self or others. Threats
involving a weapon.
____________________________________________________
Licensed Mental Health Professional Signature
Date
Page 5
Student Name: __________________________________________ Date: _____________________
o
o
TEAM CONCLUSIONS
There is NOT sufficient intent to support that the student poses a threat to self or others.
There IS sufficient information for the Team to be reasonably certain that the student DOES pose a
threat to self or others.
ACTION TAKEN
Do not leave this blank, even if transient threat)
1. School counselor will have a minimum of five (5) follow up sessions with the student. ____________________
2.___________________________________________________________________________________________
3.___________________________________________________________________________________________
4.________________________________________________________________________________________
5.___________________________________________________________________________________________
Has the parent been contacted?
_____yes _____no
If not, please explain:
___________________________________________________________________________________________
_______
__________________________________________________________________________________________________
Refer student for SBMH services?
_____yes _____no
Is student currently receiving SBMH services?
_____yes _____no
If the student is receiving SBMH services, please the therapist’s name:_________________________________________
If the therapist was not involved in the threat assessment/inquiry (for example, if threat was transient) immediately
notify the therapist regarding the threat so that it may be addressed in the next therapy session.
Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
TEAM SIGNATURES:
Administrator (REQUIRED)
Date
Licensed Mental Health Proc. (if involved) Date
School Resource Officer (if involved)
Date
School Counselor (REQUIRED)
Date
Other
Date
ORIGINAL COPY: COUNSELOR’S FILE
PAGE 6
GREENBRIER SCHOOL DISTRICT
INFORMED CONSENT TO RELEASE/OBTAIN INFROMATION
4 School Drive, Greenbrier, AR 72058
501-679-4300
Student Name: __________________________________
Date of Birth:_________________________
Student SSN:
Campus:
I, _____________________________________, parent/legal guardian of the above named student, hereby
authorize the Greenbrier School District to disclose and/or deliver records to, and additionally to obtain
records and information from:
Person/Agency
Contact Information
Purpose of Disclosure
Date
Initials
This release automatically expires 90 days after your child’s discharge from the above mentioned facility/agency.
I understand that I may revoke this authorization at any time by sending a written notice to the Greenbrier School
District, Department of Special Services, ATTN: Kim DeCorte, at the address above. I understand that any release which
has been made prior to such revocation and which was made in reliance upon this authorization shall not constitute a
breach of my rights to confidentiality.
I understand that my ability to receive treatment is not conditioned on my signing this Authorization.
______________________________________
Signature of Student (if 18) or Legal Guardian
______________
Date
SPECIFIC AUTHORIZATION FOR RELEASE OF DRUG/ALCOHOL ABUSE INFORMATION AND/OR MENTAL HEALTH
INFORMATION. I acknowledge that data to be released may include material that is both protected by Federal law and
that is applicable to either Drug/Alcohol or Mental Health Information or both. My signature authorizes release of all
such information (as specified above and for the purpose specified above.)
________________________________________________
Signature of Student (if 18) or Legal Guardian
__________________
Date
In order for the above information to be released, you must sign here and above.
Page 7
COUNSELING ASSOCIATES, INC.
SCHOOL BASED MENTAL HEALTH SERVICES
Greenbrier School District
RELEASE CONSENT
Name of Student:
Date of Birth:
School:
Social Security #:
Referral for Therapy Services
PURPOSE FOR RELEASE
AUTHORIZATION IS HEREBY GRANTED TO GREENBRIER SCHOOL DISTRICT TO RELEASE THE
FOLLOWING INFORMATION TO A THIRD PARTY:
Contact information and School Records
(Describe information to be released)
Counseling Associates, Inc.
(Name of third party)
350 Salem Road, Suite 1
(Address)
Conway, AR 73034
(City, State, Zip)
Signature of Parent/Guardian
Date
Page 8