Student Referral Form

If you are in contact with a student who has taken actions to end his or her life, please immediately seek medical assistance by calling 911.

We encourage you to refer students who are having personal problems that are interfering with their academic success. All students who have made public statements and/or have taken action that places them at risk for self-harm or harm to others should be referred. If there is any doubt about whether the student has met the requirements for referral or not, you should fill out this form. You can also consult with the Counseling Center to determine whether to complete this form.

If you encounter a student about whom you have concerns, please talk with the student and fill out this form as completely as possible. If you have any questions you can call the Counseling Center during office hours.

* required fields

Please provide the following information about yourself:

* Name:
Phone Number:
* Email address:
Your relationship to the student you are referring:

 

Please provide the following information about the student you are referring:

* Name:
* Student ID:

 

Please provide any of the following information you can about the incident:

Date of Incident:
Time:
Location:
* Briefly describe the incident:
How and when did this incident come to your attention?
* What action have you taken in regard to the incident?

 

Please answer the following questions and provide specific details as much as possible:

Yes No
Unknown
Student has made direct suicidal/homicidal threats or gestures
Describe:
Yes No
Unknown
Student has stated how they would harm themselves and/or others
Describe:
Yes No
Unknown
Student is experiencing a difficult situation (death of friend or family member, break-up, etc.)
Describe:
Yes No
Unknown
Student has been withdrawn or isolated
Yes No
Unknown
Student is experiencing academic difficulties
Yes No
Unknown
Student’s personality has changed dramatically
Yes No
Unknown
Student is under psychological or medical care that you are aware of
Yes No
Unknown
Student has a local support system
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