Student of Concern Referral Form

The purpose of this form is to provide the campus community with a vehicle to refer students to Counseling Services who are displaying signs of distress. Our intention is to respond as quickly as possible to students in distress and, as much as possible, avoid crisis situations. While it is preferable for us to know who is referring a distressed student, you can remain anonymous if you wish. Every effort is made by the Counseling Services staff to balance the need to protect the student’s well-being with the student’s right to privacy. In keeping with professional and ethical guidelines, the information obtained is not shared with anyone without the student's consent, except in the case of medical emergency or potentially life-threatening situations. Please note that this form will be seen by the Director of Counseling Services only as an anonymous HTML email.

Thank you for completing our Student of Concern Referral Form form.

Your Information

Do you wish to remain anonymous?


Student Information

Behavior and characteristics of concern (optional).