OJC Referral Form

Use this OJC Referral Form to share with us your concerns about any activity, individual or group that may exhibit signs of serious personal struggle, mental or emotional instability and /or any other behavior that is cause for you to be concerned.

To report an emergency, DO NOT use this form. Call Campus Security at 719-469-2613.
 

FIELDS MARKED WITH "*" ARE REQUIRED
Do You Wish to remain Anonymous?    
First Name:   If Anonymous Not Required
Last Name:   If Anonymous Not Required
Your EMail Address:   If Anonymous Not Required
Retype Your EMail Address:   If Anonymous Not Required
Contact Phone:   If Anonymous Not Required

I am...

I am (a)   *Required Field
 

Your concern...

Which best fits your concern?   *Required Field
Is there a specific location concerning this situation?   *Required Field
Date the incident occurred?
(Example: 04/14/2014)
  *Required Field

Your Details About the Incident

Please explain your concern, incident, complaint or grievance in the box below. Include any Students, Faculty, or Staff that were involved in this incident. Describe the behavior, not opinion. Please be as descriptive as possible. This will help us determine the course of action.
Briefly describe the details of the concern:
  *Required Field