Submit Information to Help a Herberger Institute Student
This form is NOT meant to be used for immediate concerns or emergencies, please refer to herbergerinstitute.asu.edu/caring for urgent, emergency, and after-hours resources. If a student has expressed harm to self or others, please contact the ASU Police Department at (480) 965-3456. After the emergency has been triaged, please report the concern using this form. For concerns regarding the immediate safety of yourself or others, please call 9-1-1. If you are concerned about a student in another ASU college, please complete this form.

If you are a faculty member submitting an academic concern (i.e. missing assignments, attendance issues) for a 100 or 200 level class, and the concern has no other health or wellbeing concerns, please submit an ASR instead of completing this form. 

The Herberger Institute for Design and the Arts Community of Care process gives students, faculty, staff, family members, peers, and other people the ability to make the Herberger Institute Office of Student Success aware of specific student concerns for Herberger Institute for Design and the Arts students. Once alerted about a potential student issue, Herberger Institute OSS will identify the appropriate follow-up based on the nature of the concern. If you submit a form, you will likely not hear back directly but please rest assured there are things going on behind the scenes. If you have any questions, concerns, or additional follow-up, please contact Carrie Coe, Assistant Dean of Student Services, at carrie.coe@asu.edu. 

Please fill out the following form to the best of your knowledge. A copy of your response will be sent to the email address you provide below.  
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Email *
By selecting "Yes", you acknowledge if an urgent crisis has occurred, you have contacted separate offices and are reporting this concern after contacting urgent, emergency, or after hours resources detailed on our Community of Care page. 

Urgent crisis include, but are not limited to: thoughts of hurting self, thoughts of hurting other people, have not eaten in a few days (not due to illness), recent victim of a physical or sexual assault, or concern over a student's whereabouts. 

I understand that the Herberger Institute Dean's Office meets to discuss all students submitted to this form and I understand that I may not hear back due to confidentiality and FERPA protections. *
Required
Student Contact Agreement
By checking the "Yes" box below, I am confirming I would like for the student to be contacted. 

If you do not want the student to be contacted, and need additional support in knowing how to handle this situation, please reach out to Carrie Coe, Assistant Dean of Student Services for Herberger Institute, or ASU Counseling for resources. 

Carrie Coe: carrie.coe@asu.edu
ASU Counseling: (480) 965-6146 or https://eoss.asu.edu/counseling
I agree to the student being contacted about this concern. *
Required
Does the student know they are being recommended to the Care team and that someone will be contacting them?  *
Required
Student First Name *
Student Last Name *
Student School *
If you are concerned about a student in another ASU college, please complete this form.
Student Academic Program *
If this is a masters or doctoral student, please indicate that in your response to this question. For example MFA (program name), PhD (program name)
Student ID Number (This is really helpful so if you have the ID number, we would really appreciate adding it here.)
On which campus is the student located? *
Does the student live on or off campus? *
Is the student an undergraduate first-year student? *
Definitions - Level of Concern
Minimal Concern - Concerns in which there is minimal or low impact to a student’s life and wellbeing without consequences.

Moderate Concern - Concerns in which there is low to medium impact to a student’s life and wellbeing with uncertain consequences.

Significant Concern - Concerns in which there is medium to high impact to a student’s life and wellbeing with direct consequences.

Serious Concern - Concerns in which there is high and certain impact to a student’s life and wellbeing with severe consequences or harm.

Level of Concern *
Definitions - Areas of Concern
Academic: Student needs to develop further course-based or academic skills. Examples of an concern is the area is lack of class attendance, missed assignments, or need of additional academic support.  If you are a faculty member submitting an academic concern (i.e. missing assignments, attendance issues) for a 100 or 200 level class, and the concern has no other health or wellbeing concerns, please submit an ASR instead of completing this form. 

Social/Personal: Student needs to develop personal connections with peers, staff, or faculty for a sense of belonging. Examples of a concern in this area is homesickness, isolation, or lack of engagement.

Emotional/Behavioral/Wellbeing: Student shows symptoms of depression, anxiety, or other emotional states that may inhibit their ability to succeed as a student or overall wellbeing. Examples of a concern in this area is a student acting disruptively in a classroom, disengaging from activities, or anxiety about their future.

Health/Illness/Injury: Student experiences issues in areas of health, injury, or illness. Examples of a concern in this area is a sudden injury, lack of balance in school life affecting health, or lack of sleep impacting their ability to be a successful student.

Financial/Food Insecurity: Student expresses concern over their ability to cover tuition or basic living costs in the immediate future. Use Level 4 - Serious Concern if a student has disclosed or you suspect is student is or could become homeless or cannot provide for their basic food needs.
Area of Concern for Student: *
You can select multiple, if applicable
Required
Please describe your concern, including what led to the issue. Describe what happened during the conversation or why no conversation took place. *
Referral Information for Follow-Up
Note: This information is confidential and will not be shared outside the team that works the Community of Care process. We ask for this information so that we can follow up with the referral person to provide resources as well as gather more information if needed.

Understand that the Herberger Institute Dean's Office meets to discuss all students submitted to this form and you may not hear back due to confidentiality and FERPA protections.
Name of Person Referring Student: *
Department of Person Referring Student: *
A copy of your responses will be emailed to the address you provided.
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