Student of Concern Referral Form

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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.

*If your concern is an emergency or requires immediate attention due to student safety concerns, please contact the Lycoming College Public Safety office at 570-321-4064 so your concerns can be addressed immediately.

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. Please note this form will be seen by Counseling Services only as an anonymous email. Any referrals submitted after 4:30pm Monday thru Friday, or anytime Saturday or Sunday, will be reviewed by Counseling Services staff the next business day.

Your Information

First Name

Last Name

Do you wish to remain anonymous?

Yes

No

Student Information

First Name

Last Name

Describe Your Concerns

Behavior and characteristics of concern (optional)

Has not been attending class

Has not been responding to efforts to meet and discuss academic concerns

Has been consistently inattentive and/or asleep in class

Has not been turning in class assignments

Has been verbally hostile and/or aggressive to professor and or classmates

Displays unusual degree of anxiety interpersonally or in relation to academic expectations

Displays excessive anger and acts out aggressively

Demeanor has changed from outgoing, involved and responsive to withdrawn and avoidant

Has made irrational comments and appears disoriented

Has become increasingly tearful and morose

Has acknowledged that they are depressed and overwhelmed

Has acknowledged that they are extremely anxious and overwhelmed

Has been talking about hating Lycoming and wanting to leave school

Class work and/or homework reveal consistent and disturbing interest in death, violence and/or suicide

Has made vague statements about wanting to be dead

Other students have expressed alarm and concern about this student

Has been intoxicating frequently, excessively and not attending to academic responsibilities

Consistently engages in high-risk drinking, i.e. chugging and high quantity

When intoxicated, has been engaging in very risky behavior with high potential for harm to self or others