Reporter's ID Number:
Reporter's Relationship to Student:
Please provide the student's name (first-last name) for the student you are concerned about.
Student ID Number:
Student's phone or email:
Not Required: Sometimes your records are more accurate than ours. If you have an up-to-date email and phone number for reaching the student, please provide it here.
Tell us what's going on:
Please provide as much detail as possible. Describe what behavior, statements, observations, etc., have prompted you to make this referral and when applicable, please provide specific examples. The more information we have, the more accurate our response.
What action, if any, have you taken to address the information above?:
Is the student aware this report is being made?
We have found that when you have a relationship with the student, it is helpful to let the student know that you plan to make a referral based on your concerns. Let them know why you are concerned, and how you think our office can be helpful. Remind them that the referral is designed to get them support and resources.
YOU MIGHT SAY SOMETHING LIKE:
"Thank you for telling me. I know this took a lot of courage and vulnerability. There is an office on campus, Student Outreach and Support, which helps students access success resources. I am going to make a referral and they will contact you. You may find it helpful to meet with them, talk with, and work with them to ensure you are getting the right support".
Does the student have any known trusted people in their life? (faculty, staff, friend, parent, pastor, etc.)
Are there any additional students impacted by this concern?