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Early Alert Referral Form

In addition to Individual and Group Counseling, Wellness Services offers an Early Alert Check-In phone call to any student who you believe may be experiencing or are at risk of experiencing elevated mental health challenges and may need some additional support.

Urgent and Crisis Situations

If there is an immediate risk of harm and/or threat of harm to yourself or others:

Call 911
Then call Campus Security: 780.791.4911
Please do not complete this form

For all other mental health and well-being concerns, please continue with the referral below.

How does the Early Alert process work?

Refer a student for a check-in phone call below.
Once we receive the referral, a Mental Health Coordinator will acknowledge your submission within one business day.
They may follow-up on the reason for referral if you as needed, if your contact information has been provided.
The student will be contacted for a check-in call within 24 business hours. We do not mention the name of the person who made the referral. This information will be kept confidential. For further details on our procedure, please see: the At-Risk Student Policyand Procedure.
The student will then be referred to the appropriate support resources.
If you make a referral to the Early Alert Process after hours, you will be contacted the next business day.

Indicators of Risk

At-Risk Students may exhibit the following behaviours:

Have stopped attending class;
Have stopped communicating with their instructor(s) or other Students;
Are performing poorly academically;
Are chronically absent or disinterested;
Seems isolated, withdrawn, and/or distracted;
Are exhibiting behavioural or emotional issues;

The information provided will remain confidential. If you wish, please leave your contact information, to enable us to follow-up to gather more information, if needed.
The information given will only be shared with college professionals who have required need to know.

If you have questions, additional information or wish to discuss the student concern for guidance, please reach out to wellness.services@keyano.ca

** referral source can be a student or an employee**

Full name of student

Student's email (if known)

Information related to the concern reported

If yes, how was the concern addressed?

Academic observations: Please check all boxes that apply

Repeated absence

Decline in quality of work or classroom performance

Written work that indicates disturbing content including extreme hopelessness, social isolation, rage, or despair

Other

Personal/ Interpersonal observations: Please check all boxes that apply

Implied or direct threats of self-harm

Indications of potential self-injury

Indications of suicidal ideation

Expressions of concern by other classmates or peers

Other

Physical observations: Please check all boxes that apply

Mild classroom disruption (moderate classroom discussions where risk of harm is not present may be best reported as a Non-Academic Misconduct)

Tearfulness

Expressions of hopelessness or shame

Exaggerated personality traits (e.g., more withdrawn, animated, or irritated than usual)

Direct comment(s) about distress, family problems, or other difficulties

Other

Indicators of risk

Implied or direct threats of self-harm or others

Self- Injurious or destructive (out of control) behaviour

Written work that is dominated by themes of despair, hopelessness, suicide, violence, death, or aggression

Other

Should you wish to be contacted to provide further information, please provide your email address

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Early Alert Referral Form

Urgent and Crisis Situations

How does the Early Alert process work?

Indicators of Risk