Student Outreach and Support Online Referral Form

Student Outreach & Support (SOS) at Syracuse University provides outreach, support and consultation regarding students of concern on our campus. Our goal is to provide comprehensive case management services for students who have personal/health struggles, are in distress, and/or could benefit from additional support and resources.
IMPORTANT:

While Student Outreach & Support referrals are reviewed daily, in coordination with appropriate campus partners, this form should not be used as notification for emergency situations.

If you believe that the student or community safety is at risk, there is imminent danger, and/or the situation requires immediate action, please call the Department of Public Safety at 315-443-2224.

IMPORTANT:

While Student Outreach & Support referrals are reviewed daily, in coordination with appropriate campus partners, this form should not be used as notification for emergency situations.

If you believe that the student or community safety is at risk, there is imminent danger, and/or the situation requires immediate action, please call the Department of Public Safety at 315-443-2224. I acknowledge that I have read and understand the above guidelines
Your Full Name Your Full Name First Last
Your Phone Number Your Phone Number - ### - ### ####
Your Relationship to the Student

Your Relationship to the Student Faculty/Staff Parent/Guardian Student/Friend Other Other
Your Email Address
Student(s) Being Referred:

If this is a Self-Referral, please proceed to the "Tell Us About Your Concerns" Section
Student Preferred Name Student Preferred Name First Last
SUID Number (Leave blank if you do not know SUID)
Student Phone Number Student Phone Number - ### - ### ####
Student Email Address
Tell Us About Your Concerns:
I am concerned about the following (check all that apply):

Tell Us About Your Concerns:
I am concerned about the following (check all that apply): Academic Concerns Adjustment Issues/College Transition Alcohol/Drug Use Basic Needs (Food insecurity/homelessness) Change(s) in Behavior/Odd Behaviors Change(s) in Appearance Classroom Disruption(s) Discrimination/Oppression/ Bias due to various aspects of identity Eating Concerns Excessive/Unexplained Absences from Class Financial Concerns Mental Health Physical Health Recent Traumatic Event Relationship/Family Issues Self-Injury (e.g. burning, cutting, hair pulling, picking) Sexual Assault Student Living Issue Threat to Community Threat to Wellbeing Unable to Locate Student Other Other

Student Outreach and Support Online Referral Form

Student(s) Being Referred: