Lycoming College

Student of Concern
Referral Form

The purpose of this form is to provide the campus community with a vehicle to refer students to Counseling Services who are displaying signs of distress. Our intention is to respond as quickly as possible to students in distress and, as much as possible, avoid crisis situations. While it is preferable for us to know who is referring a distressed student, you can remain anonymous if you wish. Every effort is made by the Counseling Services staff to balance the need to protect the student’s well-being with the student’s right to privacy. In keeping with professional and ethical guidelines, the information obtained is not shared with anyone without the student's consent, except in the case of medical emergency or potentially life-threatening situations. Please note that this form will be seen by the Director of Counseling Services only as an anonymous HTML email.

Referring person:  

Do you wish to remain anonymous
from the person you are referring?  yes    no

Student of Concern: 

Please describe your concerns:

Behaviors and characteristics of concern – (optional)

     Has not been attending class

     Has not been responding to efforts to meet and discuss academic concerns

     Has been consistently inattentive and/or asleep in class

     Has not been turning in class assignments

     Has been verbally hostile and/or aggressive to professor and or classmates

     Displays unusual degree of anxiety interpersonally or in relation to academic expectations

     Displays excessive anger and acts out aggressively

    Demeanor has changed from outgoing, involved and responsive to withdrawn and avoidant

     Has made irrational comments and appears disoriented

     Has become increasingly tearful and morose

     Has acknowledged that he/she is depressed and overwhelmed

     Has acknowledged that he/she is extremely anxious and overwhelmed

     Has been talking about hating Lycoming and wanting to leave school

     Class work and/or homework reveal consistent and disturbing interest in death, violence and/or suicide

     Has made vague statements about wanting to be dead

     Other students have expressed alarm and concern about this student

     Has been intoxicating frequently, excessively and not attending to academic responsibilities

     Consistently engages in high-risk drinking ie. chugging and high quantity

     When intoxicated, has been engaging in very risky behavior with high potential for harm to self or others