Early Intervention Form

The Office of Student Life is asking you to help identify students about whom you have a concern. When problems persist in spite of your involvement, you are encouraged to either call the office at (401) 456-8061 or stop by Craig Lee 119 and speak with the Dean of Students or his/her designee. Alternatively, you may complete the referral form below; however if this is an emergency, you should notify the appropriate campus authority (Dean of Students, Counseling Center, Health Services, Campus Police) immediately.

Note: This referral is not for disciplinary purposes, but rather to help a student who is experiencing a problem that may affect his/her academic success.

Please don't use this field.

Your Name
Your Telephone
Your Email
Relationship to Student
Student Information
Student's Name
Student's Email
Student's Campus Address (if known)
Student's Off-Campus Address (if known)
I am concerned because this student has (check all that apply):
	Suddenly stopped going to class without explanation
	Performed uncharacteristically below expectations on quizzes, exams and/or homework
	Had other academic problems (processing information, grasping concepts, possible learning disability)
	Not been seen in a number of days
	Talked about leaving RIC
	Had significant behavioral or mood/attitude/appearance changes
	Acted or made statements of general concern
	Presented a risk of harm to self or others
	Mentioned family/personal problems
Please provide information regarding the specific behavior(s) of concern:

Click here for Campus Resource List

This information is sent directly to the Office of Student Life. After you make a referral, we will acknowledge receipt of your submission. We also may contact you for further discussion or follow up regarding the student.

Page last updated: May. 16, 2013

Early Intervention Form

Student Information

I am concerned because this student has (check all that apply):