Student Care Referral Form

Background Information

Please provide your background information as the individual submitting this incident report.

Your Full Name:

Your Position/Title:

Your Phone Number:

Your Email Address:

Email address must be of a valid format.

Your Physical Address:

Nature of this Referral(Required):

This field is required.

Date of Incident(Required):

This field is required.

Time of Incident:

Incident Location(Required):

This field is required.

Specific location:

Please list the name(s) of the students you are concerned about.

Involved party 1

Student Name

Banner ID Number (ex. 000023459)

Questions

What is your relationship to the student(s) of concern? This field is required.

Do you know if the student lives on campus or off campus? This field is required.

If faculty/course instructor, please provide the name of your course the student of concern is enrolled in this semester. This field is required.

Please let us know the reason you are completing this form.

This is for information only and I am not requesting DOSO to reach out to the student. I think the student needs outreach and support. I am providing an update on a previous report submitted to DOSO.

You must make at least one selection.

Please indicate any of the following areas of concern that you have observed or that have been reported to you about the student.

Alcohol or Drug Abuse Anxiety Change in personal or guardian's financial status, scholarship change Changed Mood/Appearance Death close friend or family member/Grief Depression Disordered Eating Disruptive Classroom Behavior Emergency transport Expressed thoughts of suicide or self-harm Family circumstances Family Illness Financial stresses Food insecurity/hunger Housing insecurity/homelessness Implied or direct threats toward self Implied or direct threats toward others (e.g., social media postings, email, in person) Increased irritability Injury/Illness - Hospital Injury/Illness - Other Marked changes in physical hygiene, etc. Missing Student Other distressed behavior Personal Wellness Relationship Concern/Breakup with significant other Roommate conflicts Social Adjustment or Involvement Student Death Student surgery Stress Unusual Behavior Other Unsure N/A

You must make at least one selection.

Please describe the incident or behavior(s) that are currently a cause for concern. Provide as much detail as possible. Include anything that you believe may be relevant or helpful. This field is required.

What services or interventions, if any, are you aware of that the student is currently receiving? (i.e. counseling, campus coach, etc.) This field is required.

Have you connected with the student about your concern? *If Yes, please describe the nature of that contact below, and provide any relevant details. This field is required.

What strategies have you tried with the student regarding the concern? (i.e. multiple conversations, referral to counseling, extensions on assignments, etc.) This field is required.

If other WSU Departments, Offices, etc. need to be informed, please list their name, title, and email. If none, please write "none" in the text box below. This field is required.

Do we have your permission to contact the student of concern? *Regardless of your response to the question, please note that there may be an obligation to follow up with the student if a significant health or safety risk to the individual or to the university community exists. This field is required.

Do we have your permission to use your name when speaking with the student? *Note that we strive to maintain confidentiality to the extent that university, state, and federal regulations permit. This field is required.

Is the student of concern aware that a care report has been filed? This field is required.

The Care Team will follow up with you if and when we have made contact with the student of concern. If following up with you is not necessary, please select below. This field is required.

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.

Submission

Email me a copy of this report