Manor College Student of Concern Referral Form
The purpose of this form is to provide the campus community with a way to refer students to the Student Concern Team (SCT). You are encouraged to report your observations of a student who is displaying signs of intense emotional distress, inappropriate or disruptive behavior, or potentially dangerous behavior. Our intention is to respond as quickly as possible to students in distress and offer support and resources. While it is preferable for us to know who is referring a distressed student, you can remain anonymous. In keeping with professional and ethical guidelines, the information obtained is not shared with anyone without the student's consent. NOTE: If the situation involves imminent danger, where a student is in immediate danger of doing harm to self or others, you must report it immediately to the security department at 215-885-2360 extension 292 AND call 911.
Your Role (faculty, staff, student, parent, administrator)
Name of student being reported
Date of Report
Reason for Concern -Please provide a description of the behavior or situation.
Behavior and characteristics of concern (check all that apply).
Behavior regularly interferes with classroom environment or class management
Deterioration in quality or quantity of academic work
Becoming significantly more withdrawn or more animated
Displays significant depression, anxiety, or excessive moodiness
Displays hostile, intimidating, and/or aggressive speech
Displays significant decline in personal hygiene or physical appearance
Repeated abuse of alcohol and/or drugs
Engages in self-injurious behavior such as cutting or burning self
Displays strange or disorganized speech, behavior
Disturbing written or artistic expression of violence or suicide
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