Courtney's Connection
Intervention and Referral Request
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Person Providing Information
First Name
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Last Name
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Phone
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Address
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Email
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The Person of Concern Information
First Name
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Last Name
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Nickname
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Gender
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Female
Male
Prefer not to say
Grade
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Approximate Age
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If the person is in a class with you or you know of a class that they are taking, please include the following:
Room
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Period(s)
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Immediate Needs (Check all that apply)
Assistance with housing
Assistance with clothing
Assistance with food
Type of Concerning Behavior (Check all that apply)
Significant change in personal hygiene or appearance
Significant change in energy level
Change in mood, personality, or behavior
Withdrawn; Complaints of fatigue
Inability to focus or concentrate
Unusual or erratic performance, speech behaviors
Significant change in weight
Threat of self-harm
Visible injuries - cuts, burns, etc.
Farewell statements alluding to not ever seeing people again
Tearfulness or repeated episodes of crying
Giving away prized possessions
Feeling of hopelessness
Expression of worthlessness
Difficulty controlling emotions
Academic or workplace performance concerns
Excessive absenteeism; missing scheduled classes or appointments
Tardiness to class or appointments
Comments related to sleeping issues; nightmares
Direct threats toward an individual or individuals
Displays unprovoked anger, aggression or hostility
Unusual writings or drawings
Demanding
Inappropriate outbursts or reactions
Intimidating
Preoccupation with violence
Expressions of worry or anxiety
Feeling suspicious of others
Suspected drug or alcohol abuse
Odor of alcoholic beverage
Cultural factors
Problems making friends
Stares inappropriately at others
Invades personal space of others
Makes unwanted physical contact
Abusive to animals
Preoccupied with fire
Circumstances associated with the person of concern that have been reported or known to you personally:
Is not engaged in seeking treatment for diagnosed health condition
History of alcohol/drug abuse
Has suffered personal or financial loss
Destruction of property
Fire setting or arson
Suffered childhood abuse or neglect
Suffered sexual assault or abuse
Victim - History of relationship/domestic abuse
Offender - History of relationship/domestic abuse
Fantasy of harming people
History of planning a violent event
Fascination with weapons
Owns or has access to weapons
Has made homicidal statements
History of violent, reckless or antisocial behavior
History of suicide attempt
None of these apply
Other:
Please provide any additional comments below:
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