Refer Form
Referring Party Contact Information
Relationship to Student
Please select...
Faculty
Family Member
Friend/Student
Residence Director/Resident Advisor
Roommate
Self
Staff
Remain Anonymous
Your First Name
Your Last Name
Your Primary Email
Your Mobile Phone
Who Are You Referring?
Student's First Name
Student's Last Name
Nickname
Student's Mobile Phone
Student’s GU Email
Nature of Concern
Nature of Concern
Please select...
Academic
Behavioral
Both
Please select your primary concern
Please select...
Academic
Behavioral
Academic Check all that apply
Delay/failure to register
Disruptive behavior in the classroom
Excessive absences
Failing to turn in assignments
Lack of engagement in classroom/activities
Lacks essential reading/writing/or mathematics skills
Low test/quiz scores
Misuse of accommodations
Numerous requests for allowances or accommodations in regards to assignments/attendance/etc
Sleeping in class
Student discusses leaving GU
Sudden and significant decline in academic performance
Unresponsive to outreach
Please describe the academic behavior that led you to be concerned about this student
Behavior Check all that apply
Disruptive behavior
Disturbing behavior
Sudden change in mood or demeanor
Concerning use of alcohol or drugs
Self harm behaviors (cutting, scratching, etc)
Potentially risky behaviors (restricted eating, excessive exercising, binging and purging, misuse of medications, etc)
Expressions/thoughts of wanting to harm self or others
Frequent or persistent illness
Transition Issues
Loss of friend or family member
Relationship issues
Sexual assault
Domestic violence
Physical or sexual abuse
Depressed state or anxious beyond what seems normal
Thoughts or threats of suicide
Please describe the behavior(s) or situation that led you to be concerned about the student