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Refer a Student

Thank you for taking the time to complete this form. Our focus is care and concern for students who may be in distress. The Dean of Students and the Director of Counseling and Health Services coordinate resources and implement a centralized response to provide assistance to the individual and keep our community healthy and safe.

What happens once a referral is made?
Each referral is assessed, and the student will be contacted by the Dean of Students or a member of the Counseling staff. If more information is necessary, the reporting party will be contacted before contacting the student.

Background Information

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Referral Reason(Required):

This field is required.

Urgency of this report(Required):

This field is required.

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*Critical being harmful to self or others;

Date of incident(Required):

This field is required.

Location of incident(Required):

This field is required.

Involved Parties

Name of Student

Select Gender

Select Role

ID Number

Information About the Concerns

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.

Email me a copy of this report

Background Information

Involved Parties

Information About the Concerns

Supporting Documentation

Submission