UNH Franklin Pierce School of Law - Student Concern Referral

Reporter's Information

You may complete this form anonymously, but please know that anonymous reports of concerning or worrisome behavior may limit our ability to act, particularly when details are vague or unclear. Please consider providing your name and contact information in the event that we need to follow-up with you.

Your First and Last Name:

Your Phone Number:

Learn more

Consider providing a number where you could be reached after hours if needed.

Your Email:

Email address must be of a valid format.

Your UNH Affiliation(Required):

This field is required.

Incident Location(Required):

This field is required.

Specific Location:

Information about the Student of Concern

To the best of your abilities, provide the contact information for the UNH student that you're concerned about. If you're completing this form about yourself, skip this section. If you are reporting multiple students of concerns not involved in the same incident, please complete and submit one report for each student.

Student's Full Name

UNH ID

Student's Phone Number

Student's Email

Details of the Concern

Primary Concern:(Required)
Concern for the student's well-being and safety Concern for others in the community Unsure at this time
This field is required.

Please check any behaviors below that have led you to be concerned about the individual involved. If no boxes apply, please use the text box below to describe your concerns in detail:(Required)

Anger Issues

Death and Grieving a Loved One

Depression/Unexplained Crying

Disturbing Written Material/Class Discussion

Excessive Absences

Financial Insecurity

Food Insecurity

Housing Insecurity

Medical Trauma or Injury

Ongoing Academic Disruptions

Suicidal Remarks, Thoughts, or Actions

Unusual, Odd, or Dangerous Behavior

Victim of Crime or Harm

Other Concerns Not Listed

You must make at least one selection.

Date of the incident. If this has been an ongoing concern, list the date of the most recent incident.(Required)

This field is required.

Please describe the behaviors that have prompted you to share your concerns. Please use as much detail as possible, including dates for any specific incidents related to the concern. If you did not witness the behavior first-hand, please share how you came to know of this information.(Required) This field is required.

Duration of Behavior:(Required)
Single Incident Ongoing Behavior Unsure
This field is required.

Please list any other University departments or outside agencies that were contacted about the concerns you have shared; if there hasn't been any additional contact, leave this space blank. This field is required.

Have you spoken to or corresponded with the student about your concern?(Required)
Yes No
This field is required.

Have you communicated to the student that you will be submitting this referral?(Required)
Yes No
This field is required.

ACKNOWLEDGEMENT. Referrals submitted through this form will be received during normal business hours (Mon - Fri, 8:00 a.m. - 5:00 p.m.) and are not monitored after hours, on weekends, or during official University holidays.(Required)
I understand that if there is an immediate risk of harm to self or others prior to submitting this form, I should contact 911 and submit a report afterwards.
You must make at least one selection.

Additional Information

SUPPORTING DOCUMENTATION. Reports, emails, videos, text messages, audio recordings, may be uploaded in most formats (e.g., pdf, word, mov, mp3, JPEG, etc.) with the exception of shared documents. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission

Email me a copy of this report