Student Consultation Team Referral

Please use this form to report ANY self-injurious behaviors, suicidal ideation, erratic behavior that disrupts or threatens to disrupt the daily operations of the College and activities, or behaviors that might compromise safety should be referred. Anyone who feels an individual associated with CCA is a threat to himself/herself and/or the College community can make a referral. When in doubt, make the referral.

***Although several items below are not mandatory (such as names, S#’s, witnesses, etc.),
the more information that you provide, the better we will be able to address the issue.***

Name of Person Submitting:

Your S#: Example: S0123456

Your Status: *

Name of Individual With Whom You Have Concern: (Optional)

Their S#(s): (Optional) Example: S0123456

Date of Incident: *

Time of Incident: *

Location of Incident: *

Campus: *

Behavior being reported: *

Additional Witnesses (please include name and S# when possible):

Incident Details

Please describe, in as much detail as possible, specific behaviors observed. Indicate specific words, phrases, and interactions. If a person used profanity, indicate specific words/phrases used. If a person was threatening, use specific phrases of threats. If a person was disruptive, indicate behaviors associated with the disruption. Also describe injury or damage to person(s) or property. If someone has done something to raise concern, be specific in identifying the source of concern and the specific concern. Also include names of campus personnel you contacted and/or actions already taken, if any. Do not worry about the length of the report; make sure the report is comprehensive.

Incident Details: *

Community College of Aurora, 16000 E. CentreTech Pkwy, Aurora, CO 80011
Phone: 303-360-4700