Concordia University Irvine > StudentLife > Assessment-and-Care-Committee

Student's Name:

Referral By (your name):

Your phone number:

Relationship:

Check appropriate response/behavior which you have observed. This list should be used as a guide only and does not include all behavior that might concern you. Please add any other behaviors or frequency of behaviors listed below that you feel are of concern to the "additional comments" box at the bottom of this form.

Academic Performance:

Frequently ill
Lack of Motivation, apathy
Absenteeism
Declining grades or achievement
Disturbing content in coursework

Physical Symptoms:

Smelling of alcohol/pot
Glassy, bloodshot eyes; dark glasses
Coordination
Slurred speech
Change in hygiene
Dramatic change in body weight
Sleeping in class
Physical complaints and/or injuries
Change in overall appearance

Campus Employment:

Absenteeism
Tardiness
Frequently ill
Problems with authority
Inappropriate behavior
Lack of motivation, apathy
Declining quality of work

Behavior:

Severe use of alcohol/drugs
Erratic behavior change as viewed on day to day basis
Change of friends/peer groups
Disoriented (person, place, time, activity)
Inappropriate responses
Depression
Defensive
Withdrawn, loner
Argumentative
Intimidation/Threats towards others or fighting
Vandalism
Self-mutilation (cutting, burning, hair pulling)
Dramatic change in sexual behavior
Defiance of rules
Irresponsibility, blaming, denying
Sudden outburst— verbal abuse
Dramatic attention getting
Crying
Extreme negativism
Hyperactivity
Anxiety/nervousness
Preoccupation with death/suicide
Mental focus— Inability to stay on task
Problematic eating

Residential (On or Off Campus):

Prolonged absences
Disregard for other’s rights (i.e., loud music, noise)
Housekeeping concerns
Missing
Roommate conflict

Additional Comments:

This form will be sent to the Dean of Students who may contact you.

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