Employee Portal - Counseling and Consultation Services

Section 1: General Infomation

Date of Report

Location/Program

Type of Concern (check all that apply)

Staff behavior or conduct

Treatment of youth

Safety / abuse / neglect concern

Harassment or discrimination

Policy violation

Unprofessional communication

Retaliation or favoritism

Workplace conflict

OtherOther

Section 2: Description of Concern

What happened? *

(Encourage detail — date(s), time(s), what was said/done, where, who was involved, and any witnesses)

How often has this happened?

Once

Occasionally

Repeatedly / Ongoing

When did this occur?

Within the last week

Within the last month

Over a month ago

Ongoing

Who was involved?

(First names or positions only — optional)

Have you reported this before?

Yes (to whom?)Yes (to whom?)

No

Section 3: Impact & Safety

How has this issue affected you or others?

Does this issue pose an immediate safety risk to anyone?

Yes

No

If yes, please explain — this will be addressed immediately.

Section 4: Preferences

Would you like someone to follow up?

Yes — I’m open to being contacted (I understand HR may need to identify my report to do so)

No — I prefer to remain anonymous

If yes, provide a safe contact method (optional):

Phone, email, or internal contact person

Would you like this to be addressed privately, or discussed with leadership?

Privately (HR only)

Leadership team may review if needed

No preference

Section 5: Acknowledgment

All reports are reviewed by HR or designated leadership.
No retaliation will be tolerated for good-faith reporting.
If this is an emergency or immediate safety concern, please contact your supervisor or HR immediately.

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