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Person of Concern Health and Safety Referral

Do not use for immediate Crisis/Emergency
Call 911 or campus law enforcement at (719) 549-2373

If you are concerned about the health, well being, or safety of any individual on campus, you may complete this form.

Examples of why you may fill out the form include persons who are:

  • Harmful to themselves or others
  • Making suicidal threats or gestures
  • Exhibiting alcohol or drug problems
  • Exhibiting a pattern of bizarre behaviors or actions
  • Experiencing hospitalization for psychiatric, drug or alcohol problems
  • Disruptive to the living or learning community

This is obviously not a complete list, but should give some idea of types of issues of concern.

Please complete the form if you have any reason to worry about a personís health or safety. This form is designed to help the person you are concerned about, not to punish him or her. You may remain anonymous and still submit this report, so you do not need to fear negative consequences to you for filling this out. The form will be reviewed in order to determine the best way to help manage the situation. This could include meeting with the person filing out this form or contacting the person of concern.

Answer as best you can. Fill out as many of the following questions as you can.

Items indicated with the > are required fields to process your request.

Person being referred:

  

  

  

  

 
Example: (xxx) xxx-xxxx

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Information about the originator of the report:

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Example: (xxx) xxx-xxxx

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