Care Concern Graduate Student Referral and Support » Office of Graduate Education » College of Medicine

I understand that this form must NOT be used to report emergencies. Emergencies include students who are actively suicidal, homicidal, or in need of immediate follow-up. Please contact UFPD or dial 911 for emergencies and submit a Care Referral afterward.(Required)

Yes

Your Contact Information: (only referral source is required)

Full Name

Your Phone Number

Your Email Address

Referral Source(Required)

Student of Concern Information

Full Name(Required)

UFID (if available)

Email Address (if available)

Program (and concentration if a BMS student) (if available)

Faculty Mentor (if known)

Student Referral

Type of Concern

Safety Risk Concerns (Please select any that apply): Please contact the University of Florida Police Department at (352) 392-1111, local law enforcement at 911.

Written or verbal statements which mention threats, suicide and/or death

Severe feelings of hopelessness, sadness, isolation, and/or withdrawal

Statements such as “going away for a long time” made by the student

Other (please specify in narrative below)

Other

Academic Concerns (Please select any that apply):

Repeated absences from class, section, or lab

Missed assignments, exams, or appointments

Deterioration in quality or quantity of work

Other (please specify in narrative below)

Other

Behavioral and Emotional Concerns (Please select any that apply):

Direct statements indicating distress, family problems, or loss

Angry or hostile outbursts, yelling, or aggressive comments

More withdrawn or more animated than usual

Expressions of hopelessness or worthlessness: crying or tearfulness

Expressions of severe anxiety or irritability

Other (please specify in narrative below)

Other

Physical Concerns (Please select any that apply):

Showing a marked change in appearance

Statements about change in health, appetite or sleep

Noticeable cuts, bruises, or burns

Disorganized speech, rapid or slurred speech, confusion

Other (please specify in narrative below)

Other

Basic needs (Please select any that apply):

Financial Hardship

Food Insecurities

Housing Insecurities

Other (please specify in narrative below)

Other

Community & Belonging (Please select any that apply)

Feelings of not belonging

Lack of awareness about campus events/resources

Loneliness

Miscellaneous concerns (Please select any that apply):

Death of Family Member

Death of Fellow Student

Death of Non-Student/Other

Misuse of Drugs

Misuse of Alcohol

Student Impacted by an Event

Unable to Locate Student

Witness to an Incident

Other (please specify in narrative below)

Please provide a detailed description of the concern.(Required)

How would you prefer that a staff member from Student Affairs follow up with you?(Required)

Follow-up is not necessary

Follow-up via phone

Follow-up via e-mail

Follow up in-person by meeting with a staff member from Student Affairs

Reporting Student Incident

Emergency Services Response, please select any that occurred:

Police and/or Campus Safety were called to the incident

The student was transported to jail or other location

The student was transported to the hospital or taken to the Counseling and Wellness Center

Other (please specify in narrative below)

Other

Supporting Documentation

Photos, video, email, and other supporting documents may be attached using the link provided after you submit this form.