• Self
  • Other

Type of Concern

  • Mental Health (depression, etc.)
  • Academic Performance
  • Accident/Trauma
  • Poverty (including homelessness, hunger, unpaid bills, etc.)
  • Assault (such as sexual assault)
  • Other

Has this behavior been observed in the past?

  • Yes
  • No
  • Don't Know

How would you rate the risk that this person will harm self and/or others?

  • No risk
  • Little risk
  • Moderate risk
  • High risk
  • Imminent risk requiring immediate action

Have you informed anyone else about this concern?

  • No
  • Yes