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Dean of Students Office Walk-In/Referral Form


Please take a few minutes to complete the Dean of Students Intake Form. Your responses will be used to provide you the most useful services possible.

Before filling out this form, please review the below information regarding the privacy of your information in the Dean of Students Office:

The Family Educational Rights and Privacy Act (FERPA) of 1974, and its amendments, is a federal law that protects the privacy of a student’s education records. Education records are any records that contain information that is directly related to the student and are maintained by the institution or a party acting for the institution. With this in mind, the University of Wisconsin-Platteville faculty and staff are unable to share information with members of a student’s family or other third parties without the express written consent from the student themselves. Some exceptions are noted below:

--Dean of Students Office staff may need to share information with the proper authorities if there is evidence that a student is in imminent danger of harm to self or others. The purpose of sharing this information is to ensure safety and provide necessary support.

--Dean of Students Office staff may need to contact emergency contact information, families/parent contacts, if there is significant concern for the health and well-being of a student at UW-Platteville.

--Under the Clery Act and Title IX, Dean of Students Office staff may need to disclose certain information, to the proper campus officials, about crimes on campus (Clery Act) and sexual misconduct (Title IX).

If you have any questions or concerns regarding this information, please talk with Dean of Students Office staff during your meeting. We want to be sure to answer any questions that you may have.

Intake Information

 
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Involved Parties

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Questions

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Please check any of the below stressors or concerns that you are currently experiencing:(Required)
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Are you interested in receiving information about any of these services? (Please check all that apply)(Required)
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Were you referred to the Dean of Students by any of the following:(Required)
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