Student of Concern Form

 The form below is one way you can share that you are concerned about a student.  Fill in as much information as you can.  Someone from the Student Support Services Office or their designee will reach out to provide the student support and resources.  If you would prefer to discuss your concern with someone, you can call Student Support Services at 509-313-4009.

Please be aware that this form goes to the Gonzaga University Student Support Services Office during normal business hours.  It is not monitored after hours, on weekends, or on University holidays.  Gonzaga has Campus Public Safety and Security and Student Development staff available to respond to immediate concerns 24 hours a day, 365 days a year.  If you have immediate concerns about the health or safety of a student or of the Gonzaga community because of a student, call Campus Public Safety and Security at 509-313-2222.  Gonzaga Dispatch can get you in touch with the appropriate assistance for your concern. If there is an active emergency, call 911 immediately.    

 Provide as much information as you can on the form below.  You can fill out as much or as little information as you want.  The more information you can provide us, the better we can serve the student you are concerned about.  If you provide your contact information, we may get in touch with you to get more information prior to contacting the student.  We do everything we can to preserve your anonymity, but cannot promise complete confidentiality.

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* = Required Fields
Contact Information
Yes No
Student Information
Freshman
Sophomore
Junior
Senior
Graduate Student
Other
On Campus Off Campus Unknown
Academic

For example:
  • Significant decline in academic performance
  • Excessive absences from class
  • Failing to turn in assignments
  • Student has stated (either verbally or written) that she/he is concerned about academic performance
  • Numerous requests for allowances or accommodations in regards to assignments/attendance, etc
Behavioral

For example:
  • Disruptive behavior
  • Disturbing behavior
  • Sudden change in mood or demeanor
  • Concerning use of alcohol or drugs
  • Self harm behaviors (cutting, scratching, etc)
  • Potentially risky behaviors (restricted eating, excessive exercising, binging and purging, misuse of medications, etc)
  • Expressions/thoughts of wanting to harm self or others
Social/Emotional

For example:
  • Loss of friend or family member
  • Relationship issues
  • Sexual assault or domestic violence
  • Physical or sexual abuse
  • Depressed state or anxious beyond what seems normal
  • Thoughts or threats of suicide
Other

Please explain: