Student Care Report
Urgency of Report
Urgent (safety concern for self or others)
Concerning (follow up in a timely fashion)
Date of Incident
Date Picker Icon
Location of Incident
Student Name or Organization
Information of Concern
Please describe the behaviors that have prompted you to share your concerns. Please use as much detail as possible, including dates for any specific concerns. If the concern involves threats or comments related to self-harm or harm to others, please include exact quotes and how these comments were communicated.
Based on the description you provided, please check any behaviors below that have led you to be concerned about the individual involved (optional).
Depressed/Persistent Sadness/Unexplained Crying
Display or Use of Weapon
Disruptive Classroom Behavior
Disturbed Eating Behaviors
Disturbing Written Material/Class Discussion
Extreme Mood Swings
Inappropriate Display of Anger/Negative Emotions
Involves Alcohol/Drug Use
Significant Change in Appearance/Behavior
Stalking (including Cyber Stalking)
Unexplained Absences (after multiple contact attempts)
Have you talked to or communicated with this student about your concern?
Yes (**NOTE: If you have talked to or communicated with this student about your concern, please describe it in the communication section below.)
Please describe your communication with this student about the concern (e.g., format, frequency, response).
I understand that referrals from this form will be received during normal business hours (M-F, 8:00 AM - 4:30 PM) and are not monitored after hours, on weekends, or during official university holidays. Please contact campus security at 248-765-8013 if there is an immediate risk of harm to self or others prior to submitting this form.
Yes, I understand.
I understand that the receipt of my referral will be acknowledged through email by the Student Care Team, and I understand that only limited follow up information will be available to the reporting party in order to protect student privacy. I also understand that it is important to provide the Student Care Team with any updates on the student's behavior.
Yes, I understand.
If you have any supporting documentation, such as images or other files, please submit them here. 1GB maximum total size. Attachments require time to upload, so please be patient after submitting this form.
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