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 Center for Cura Personalis, or their designee, will reach out to provide the student support and resources.  If you would prefer to discuss your concern with someone directly, you can call the Center for Cura Personalis directly at 509-313-2227.

The more information you can provide us, the better we can serve the student about whom you are concerned.  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.

Please be aware that this form goes to the Gonzaga University Center for Cura Personalis during normal business hours.  It is not monitored after hours, on weekends, or on University holidays.  Gonzaga has Campus Security and Public Safety 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 Security and Public Safety 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. 

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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: