Student Care Referral

Background Information

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Your full name:

Your role or position at Elon:

Your phone number:

Your email address:

Email address must be of a valid format.

Date of incident/report(Required):

This field is required.

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Please enter date of report for general concerns with no incident date

Location of incident(Required):

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Specific location:

Involved Parties

Please include information for the student about whom you are concerned. If there are others who may have witnessed or been impacted by concerning behavior, please include their names(s) and contact information.

Person's Name

Person's Role

University ID Number (if known)

Phone number (if known)

Elon Email address

Describe the Incident/Concern

Please describe the behaviors that have prompted you to share your concerns. Please use as much detail as possible. If the student has made any comments indicating possible harm to self or others, please include specific statements that were made and provide any context that may be helpful to better understand the situation. If you are aware of other relevant history or concerns, please share those as well.(Required) This field is required.

Are you aware of whether this student is already connected with certain resources for support? This could include a range of offices or individuals, including counseling, learning assistance, identity-related support, important mentors, etc.. If so, please include that here as context for our staff. This field is required.

Lastly, are there any additional steps you have taken personally to support this student that you have not already included above? This could include a plan you created with the student, a conversation you had with the student, or other steps taken. 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.

Email me a copy of this report

Background Information

Involved Parties

Describe the Incident/Concern

Supporting Documentation

Submission