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.

I am a:


How to Contact You

Preferred way to contact you:


Incident Report

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

Was there a direct threat to self or others?: