Early Alert Referral Form

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

Essay or creative work that indicate disturbing content including extreme hopelessness, social isolation, rage, or despair

Classroom disruption

Other

Personal/ Interpersonal observations: Please check all boxes that apply

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

Physical observations: Please check all boxes that apply

Tearfulness

Expressions of hopelessness or shame

Exaggerated personality traits (e.g., more withdrawn, animated, or irritated more than usual)

Direct comment about distress, family problems, or other difficulties

Expressions of concern by other classmates or peers

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