Mental Health and/or Substance Misuse

Reporter Information

Please provide your contact information so that we may follow up with you as needed.

The team can address submissions most completely when are able to communicate with people reporting. The benefits of direct reporting include a greater ability for Lafayette to understand the situation, provide resources, support, and options to those reporting, and to address the behavior fully and accurately.

We do accept anonymous reports. Those wishing to report anonymously may submit this form without identifying information. If you choose to submit a report anonymously, please note that Lafayette will strive to fully respond, but anonymous reporting significantly limits our ability to do so.

If you submit this form with your name or contact information, a member of the Student Support and Intervention Team will contact you to verify receipt of the report, to ask any clarifying questions they may have, and to offer you relevant resources.

To learn more about confidential resources, please visit: https://deanofstudents.lafayette.edu/confidential-resources/

Your full name:

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Please include your first and last name

Your title or class year:

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If you are unaffiliated with the College, type N/A

Your phone number(s):

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Please include all numbers where you can be reached

Your email address:

Email address must be of a valid format.

Nature of Concern(Required):

This field is required.

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Please select the nature of your concern:

Date of incident(Required):

This field is required.

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Approximate date behavior was first observed, if known

Location of incident(Required):

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Specific location:

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Examples include room numbers, floors, outdoor locations, etc.

Involved Parties

Please provide as much identifying information as possible for all individuals involved in the situation you are reporting. Please include information regarding other individuals who may have additional information about the student you are concerned about.

Name

Select Role

Phone number

Hall/Address

Questions

Please respond to the following prompts as appropriate to the fullest extent possible.

Please describe what you know about the situation. Be as detailed as possible. This field is required.

Have you addressed your concerns directly with the individual?(Required)

Yes No

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If yes, please share how you addressed your concern and how they responded. This field is required.

How would you prefer to be contacted should we need additional information?(Required)

E-mail Cell phone Office phone

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Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Reporter Information

Involved Parties

Questions

Supporting Documentation

Submission