Refer a Student

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Thank you for sharing your concerns for a student at the University of Illinois, Urbana-Champaign.

BEFORE YOU BEGIN: If this is an emergency that involves an imminent risk of harm to self or others, please contact campus police at (217) 333-1216 or by dialing 911 BEFORE filling out this referral form. Referrals are reviewed during normal business hours and are not monitored after hours, on weekends, or during official University holidays. Although referrals from this form are reviewed by a variety of campus partners working to assist students, it is NOT designed for emergency response situations.

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Refer a Student

Tell us about you:

Your full name:

Your position/title:

Your phone number: answer must be phone number with area code like 217-333-1000

Your email address: answer must be an email address

Tell us about who you are concerned about:

Person's full name:

Gender:

UIN: (9 digit number) answer must be a university ID like 612345678

Other information you may have (ex. Netid/email, major, date of birth, etc.):

Please list the same information (name, gender, UIN, etc.) below if there are multiple students.

Tell us about your concerns:

Date of incident: answer must be date like mm/dd/yyyy

Time of incident:

Location of incident:

Based on the description you provided, please check any behaviors below that have led you to be concerned about the individual involved:

Please list any other University departments or outside agencies that were contacted about the concerns you have shared:

Please indicate if any of the following actions were taken as a result of the concerns you have described:

Please acknowledge your understanding of the statement above

Supporting documentation:

Attachment: (maximum file size: 50MB)

Attachment: (maximum file size: 50MB)

Attachment: (maximum file size: 50MB)

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