Counseling Incident Report Form
Use this form to document and report details of a counseling-related incident. Please provide accurate and thorough information for record-keeping and follow-up.
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Name of Person(s) Involved
*
Role of Person(s) Involved (e.g., Student, Counselor, Staff)
*
Description of Incident
*
Actions Taken During or After the Incident
*
Was any follow-up required?
*
Yes
No
If follow-up is required, please specify
Name of Reporting Counselor
*
First Name
Last Name
Submit Report
Should be Empty: