Home » Student Affairs » Student Support & CARE Team » Refer Faculty/Staff/Student Refer a Faculty/Staff/Student Form Please use this form to submit your information. For any questions please contact *protected email* Thank you. "*" indicates required fields Presenting Concern*Please check all that apply Substantial academic or work performance concern Anxiety/depression COVID-19 Family issue including caregiving responsibilities Financial distress General stress Loneliness/isolation Loss/Grief Medical Relationship violence/stalking/sexual harassment Sexual Assault Suicidal ideation Suicide attempt Substance abuse Other (specify below) Other Concern:Tell Us Who You AreAffiliation* Faculty Staff Student Family/friend Patient/client Visitor Unaffiliated with MUIH Your Name*Note: If you wish to be anonymous, please write in “anonymous” but please understand this may limit the extent to which we are able to address the concern First Last Your EmailNot Required Your Phone NumberNot RequiredTell Us About the Person You are Concerned AboutName* First Last ID Number, if knownNot Required Other individuals who may be involved or affectedPlease press + to add a new item.First NameLast Name Add RemoveTell Us About Your ConcernPlease include specific behaviors/incidents*Please attach supporting documentsOptional Drop files here or Select files Max. file size: 50 MB. Your ResponseHave you or another member of your department addressed the concern with the individual?* Yes No Unsure If yes, what did you do and what was the outcome?OptionalReferrals that you made, if applicable.Check all that apply Academic Advising Academic Success Disability Services and Accessibility Career Services Counseling and Referral Services (students) or Employee Assistance Program (faculty/staff) Employee Assistance Program Financial Aid Human Enrichment Natural Care Center Student Accounts Student Conduct & Conflict Resolution Title IX Coordinator Other (specify below) Other Referral:CommentsThis field is for validation purposes and should be left unchanged.