Dean of Students Office Referral Form

Your Information

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Urgency of this report(Required):

This field is required.

Student of Concern

Name or Organization

GTID Number (ie: 901555555)

Phone number

Email address

Questions

If this is an emergency call GTPD at 404-894-2500.(Required)

Yes No

This field is required.

What causes you to be concerned for this student? Please share any specific interactions, correspondence, or conversations you have had with this student that have caused you to be concerned. If you have any documentation (e.g., photos, emails, video, other documents, etc.), you can attach them below under Supporting Documentation.(Required) This field is required.

Is the student aware that you are sharing your concern with the Dean of Students Office?(Required)

Yes No Unsure

You must make at least one selection.

Have you addressed this concern with the student? (email, phone, face to face, text)(Required)

Yes No

You must make at least one selection.

Please add any additional comments, information, or observations you wish to share. This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Dean of Students Office Referral Form

Please use your real contact information in case we need to follow up with any questions. Your name will be kept confidential when contacting the student.

Your Information

Student of Concern

Questions

Supporting Documentation

Submission