Student Affairs Referral Form

This electronic form is for referral purposes. If this is an emergency, please call 911.
The Office of Student Affairs is unable to accept anonymous referrals. To the extent possible, Student Affairs will maintain confidentiality regarding the reporter. However, we may need to contact you for further information. Depending on the nature of the referral, we may not be able to provide you with feedback regarding your referral. We appreciate your cooperation and understanding. Thank you for completing the information below in full.

Please contact the Office of Student Affairs by E-Mail or 304-384-6035 or 304-384-5231 if you prefer to discuss the situation, rather than complete the form.

Reporter’s Contact Information
Reporter’s Name (required) Reporter’s Name (required) * First Last
Reporter’s Role (required) *

Reporter’s Role (required) Faculty/Staff Student/Student Employee (including self referrals) Parent/Guardian Other Other
Daytime Phone (required) Daytime Phone (required) * - ### - ### ####
Evening/Weekend Phone (required) Evening/Weekend Phone (required) * - ### - ### ####
Email
Referral Information
Does the student prefer to remain anonymous? (required) *

Does the student prefer to remain anonymous? (required) Yes No
If you don't know the full name of the student, Enter Unknown in the box (Example: John Unknown or Unknown Doe).
Name of Student being referred (required) Name of Student being referred (required) * First Last
Student ID number, if known
Student Phone Student Phone - ### - ### ####
Reason for Report/Referral (required) *

Reason for Report/Referral (required) Academic Psychological/Behavioral Self-harm, including thoughts of suicide (Authorities may be notified) Harm/Threat to Others (Authorities may be notified) Sexual Harassment or Sexual Assault Other Other
Would you like to send a copy of this referral to University Police? (required) *

Would you like to send a copy of this referral to University Police? (required) Yes No
Please describe the reason for the referral (required): *
Is the referral related to a specific incident? (e.g. suicide threat/attempt, sexual assault, stalking incident, classroom disruption, etc.) (required) *

Is the referral related to a specific incident? (e.g. suicide threat/attempt, sexual assault, stalking incident, classroom disruption, etc.) (required) Yes No
Date of Incident
Month
Day
Year
Date is (required): *
Please describe the incident (required): *
Names and contact information of others who may be witnesses to the incident:
Please add any additional information you wish to provide regarding this referral:

Student Affairs Referral Form

Student Affairs Referral Form

Reporter’s Contact Information

Referral Information

If you don't know the full name of the student, Enter Unknown in the box (Example: John Unknown or Unknown Doe).

Date of Incident