RCCD
RCC Cares/BIRT Referral
Referral For. . .
☐STUDENT CONDUCT OF CONCERN ☐BEHAVIORAL CONCERN
ID:
Date:
Contact Phone:
Student’s Name:
Date(s) of concern:
Reported by:
Check any that apply:
☐ Personal/mental health concern.
☐ Suicidality.
☐ Hunger or homeless concern.
☐ Family concerns.
☐ Classroom concerns.
☐ Alleged violation of college rules and regulations including those concerning student
organizations, the use of college facilities, or the time place and manner of public expression or
distribution of materials.
☐ Forgery, alteration, or misuse of college documents, records, or information to the college
activities.
☐ Obstruction or disruption of classes, administration, disciplinary procedures, or authorized
college activities.
☐ Theft of or damage to property or possession of stolen property belonging to the college, a
member of the college community, or a campus visitor.
☐ Use, possession, distribution of alcoholic beverages, narcotics, hallucinogenic drugs,
marijuana, or other dangerous drugs; or presence on campus while under the influence alcoholic
beverages, narcotics, hallucinogenic drugs, marijuana, as other dangerous drugs, except as
expressly permitted by law.
☐ Other concern(s) as outlined below
The behavior of concern occurred as described below (attach supporting documents, if necessary).
Please include a statement about any prior history or incidents regarding the student of concern:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The following action is requested:
☐ INFORMAL CONSULTATION REFERRAL
The reporter may request a consultation with RCC Cares/BIRT. The student may or may not be notified of the
report but may not necessarily be required to meet with a school official. Informal referrals are for relatively
minor concerns and may be retained to determine if a pattern of behavior is observed that may lead to formal
action. An informal referral will not necessarily result in any specific action.
☐ FORMAL DISCIPLINARY or CONCERN REFERRAL
The student and/or the reporter will meet with the college official(s). Students have full rights of due
process as outlined in the Student Handbook.
Plea
se return this form to Dr. Renee Martin-Thornton, Director, Student Health and Psychological Services
renee.martin-thornton@rcc.edu
(951) 222-8048
