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Safety Assessment Referral Form

Fields marked with  are required.

About yourself

Name


Phone


Relationship to person




About person

Status




Name:


Phone


Address


Gender


Age


Ethnicity


About incident

Date (MM/dd/yy)


Time


Briefly describe the incident


How and when did this incident come to your attention?


What action have you taken in regard to the incident?


Please provide any additional information you have:


If yes, please describe

Person has said things such as
“I’d be better off dead” or “I wish I could just disappear”

Person has told you or others that they
want to harm themselves or others

Person has communicated how they
would harm themselves or others

Person has made direct threats or gestures
Person is experiencing a difficult situation
(death of friend or family member, break-up, etc.)

Who are you concerned this person will harm?
Person has made previous attempts to harm self or others
Person has been withdrawn or isolated
-(for example, person sleeps excessively, doesn’t want to leave his or her home, or skips an excessive number of classes)

Person is experiencing academic difficulties
Person’s personality has changed dramatically
Person has been using excessive (or more than usual) alcohol or drugs
Person is under psychological or medical care
Person has a local support system