• This form can be used for the following:

  1) Concerns about a student's mental state and well-being.
  2) To help provide referral and resource information or to provide counseling/resources.
  3) Concerns about disruptive or inappropriate behaviors in the classroom or on campus.
  4) Concerns about a student representing a threat to themselves or others.
  **If there is an immediate emergency, please call 9-1-1 or Public Safety at 719-255-3111
  
  All fields marked with (*) are required. You may choose to remain anonymous, but your identity may help us in the investigation.

• Your Name*

  First Name

  Last Name
• I am a*

  Student	Friend	Parent
  Faculty/Staff	Other
• If Faculty/Staff, please indicate office or department affiliation*

• How to Contact You

• Email Address*

  eg. jdoe@uccs.edu
• Phone Number*
• Preferred way to contact you*

  Phone	E-mail	No Thanks

• Incident Report

  Please be as detailed as possible. The more information, the better we can assist you.

• Student(s) Being Referred*

  Name, Email if known
• Student ID#*

  If known
• Date(s) of Incident*
• Type of Concern*

  Type of Concern General Concern about Mental Health and Well-being Disruption of Classroom or Community Suicidal Ideation/Depression Threat of Harm To Others Threat of Harm to Self Substance Abuse - Drugs Substance Abuse - Alcohol Sudden Change in Appearance, Behavior, Attitude Eating Disorder Concern Other
• Please Describe the Incident*
• Witness(es)*
• Was there a direct threat to self or others?*

  Yes

  No

If there is an immediate emergency, please call 9-1-1 or Public Safety at 719-255-3111