• This form can be used for the following:
  1. Concerns about a student's mental state and well-being.
  2. To help provide referral and resource information or to provide counseling/resources.
  3. Concerns about disruptive or inappropriate behaviors in the classroom or on campus.
  
  If you are concerned about any immediate threat of harm to self or others –
  DO NOT USE THIS FORM.
  Contact Public Safety immediately. 518-783-2999.

• Your Name First Last
• Your Email Address
• Your Phone Number - (###) - ### ####
• Your Role on Campus* Faculty / Staff Student Other
• Date/Time of Incident* MM/DD/YYYY
• Location
• Type of concern (check all that apply)* General Concern about Mental Health and Wellbeing Disruption of Classroom or Community Suicidal Ideation/Depression Threat of Harm to Self Substance Abuse - Drugs Substance Abuse - Alcohol Sudden change in Appearance, Behavior, Attitude Eating Disorder Concern
• Student(s) Being Referred*
  Include first and last name, email, phone and SID Number if known
• Description of Incident/Concerns - please be as detailed as possible*

• Remember, you are invided to contact John Felio, the Dean of Students, directly if you prefer. jfelio@siena.edu

• Leave this field blank

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