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Student Assistance and Support Referral Report


BEFORE YOU BEGIN: If this is an EMERGENCY situation, CALL 911 or contact the University of Illinois at Chicago (UIC) Police Department at (312) 355-5555. Call 5-5555 if calling from a campus phone. Do not use this form to report events that present an immediate threat to health or safety. Additionally, do not upload confidential or sensitive material such as hospital records, credit card statements, etc. 

Student Assistance and Support Referral Reports will only be reviewed during normal business hours, Monday - Friday 9:00 AM to 5:00 PM, and are not monitored after hours, on weekends, or during official University holidays. While referrals from this form are reviewed by a variety of campus partners working to assist students, it is NOT designed for emergency response situation.

The Office of the Dean of Students works directly with students to find solutions to situations that are negatively impacting their personal/social lives (Advocacy) and/or their student status at UIC (Ombuds). We coordinate resources and implement a centralized response to provide assistance to individuals while keeping our community healthy and safe. Our services are designed to work with faculty, staff, and students in identifying and addressing student concerns BEFORE they reach a level of violating the Standards of Conduct per the Student Disciplinary Policy .

For assistance or consultation while completing this referral report, please contact the Office of the Dean of Students at 312-996-4857.

Background Information

 
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Email address must be of a valid format.
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Person(s) of Concern

Please provide as much information as possible about the student who may be exhibiting concerning behavior.

Involved party 1

Reason(s) for Report

This form can be used for self referral or for the purpose of reporting a concern about behavior of others. Please use the checklist below and, in the narrative section, provide detailed information regarding the concern you are reporting.

ACADEMIC CONCERNS
You must make at least one selection.
BEHAVIOR CONCERNS
You must make at least one selection.
PERSONAL CONCERNS
You must make at least one selection.
MENTAL HEALTH CONCERNS
You must make at least one selection.
This field is required.
This field is required.
This field is required.
This field is required.
I understand that this report will only be reviewed during normal business hours, Monday - Friday 9:00 AM to 5:00 PM, and are not monitored after hours, on weekends, or during official University holidays. If I believe there is an immediate risk of harm to self or others, I will contact UICPD at (312) 355-5555 prior to submitting this report.(Required)
You must make at least one selection.

Supporting Documentation

Please upload any documents, pictures, videos, or screenshots that would help us better understand the matter you are referring. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission