Student Wellness Intervention and Facilitation

The Vice President of Student Services and other members of SWIFT seek your assistance in identifying KC students who are in need of guidance and support. The purpose of this report is for you to be able to alert us to students whose actions and behaviors are causing concern. This report will not be used to initiate disciplinary action but rather to get help for the student.

If you believe the student or the campus/community is in IMMEDIATE danger, please contact Security at x3199 or call 911 (9-911) from a campus phone.

*Date Reported

April 2024 Sun Mon Tue Wed Thu Fri Sat 14 31 1 2 3 4 5 6 15 7 8 9 10 11 12 13 16 14 15 16 17 18 19 20 17 21 22 23 24 25 26 27 18 28 29 30 1 2 3 4 19 5 6 7 8 9 10 11 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec TodayClear

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*Semester

Fall Term Spring Term Summer Term

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*Student Name

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Student ID Number (If known)

Student Phone Number (If known)

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Risk Assessment
*Level of Concern

Low Medium High

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Behaviors of Concern
Select all behaviors or concerns that you wish to bring to the attention of the Student Wellness and Intervention Facilitation Team.
Mild Risk

Emotionally Troubled (depressed, manic, unstable, hopelessness, anxiety) Dealing with Situational Stressors or Traumatic Events (family issues, life changes, etc) Disruptive behavior (classroom, on campus or at Ed Center) Exhibiting signs of distress/appearance change (decreased self care, hygiene, etc) Expressions of self harm/suicide (denied, unclear, no plan, vague) Expressions of intent to harm others (denied, unclear, no plan, vague) Other...

Moderate Risk

Repeated or more involved disruptive behavior (classroom, on campus, or at Ed Center) Computer misuse/inappropriate interests Increased signs of distress (changes in appearance or hygiene, eating issues, adjustment concerns) Possible threat (made or perceived) (threat content suggests it is unlikely to be carried out) Emotionally troubled (depressed, manic, unstable, hopelessness, anxiety) Expressions of self harm/suicide (vague, indirect, inconsistent, implausible, lacks detail, lacks realism) Expressions of intent to harm others (vague, indirect, inconsistent, implausible, lacks detail, lacks realism) Other...

Elevated Risk

Increasingly disruptive or concerning behavior, unusual or bizarre behavior or incidents, seriously disruptive incidents Exhibiting clear distress (seriously depressed, manic, unstable, hopelessness, anxiety, panic) Substance abuse (drugs, alcohol), self medication, noticeably under the influence of behavior altering substances Threat made or present (threat content suggests it is unlikely to be carried out) Expressions of self harm/suicide (vague, indirect, repeated or shared with multiple people, inconsistent, implausible, lacks detail, lacks realism) Expressions of intent to harm others (vague, indirect, repeated or shared with multiple people, inconsistent, implausible, lacks detail, lacks realism) Destructive behavior exhibited, (harmful to self or threatening to others or property) Cyber stalking Cyber stalking Verbal/Written aggression Other...

Severe Risk

Engaging in risk taking behaviors (substance abuse or overload, physical signs of harm, cutting, etc) Severe distress, (disoriented/disorganized, cannot regulate emotion, paranoid delusions/bizarre thoughts, control self/behaviors, extreme abuse/harmful relationships) Threats made and present (vague and direct or specific but indirect) (threat content suggests it may be carried out) Expressions of self harm/suicide (concrete, specific and direct, repeated or shared with multiple people, consistent, plausible, includes increasing detail of a plan, repeated with consistency, tries to convince others they are serious) Acutely suicidal thoughts, feelings, expressed intentions and ideations Expressions of intent to harm others (concrete, specific and direct, repeated or shared with multiple people, consistent, plausible, includes increasing detail of a plan, repeated with consistency, tries to convince others they are serious) Physical stalking Verbal and/or physical aggression Weapons Other...

Extreme Risk (Requires immediate intervention - Call 911)

Extreme distress (psychotic break, detached view of reality, profoundly disturbed, unable to care for self, at risk of grievous injury or death without death without intent to self-harmdeath without intent to self-harm) Para-suicidal (extreme self injury/ self injurious behavior, eating disorder, personality disorder) at life-threatening levels Physical aggression (hostile, aggressive, relationally abusive) Threat made or present (threat is concrete and specific or direct) Extreme risk of suicide (definite plan, time, place, means, giving away possessions, written notes, steps may already have been taken, sudden calm after expressing suicidal ideations and intentions) Expressions of intent to harm others (definite plan, time, place, means, repeated with consistency, steps may already have been taken) Weapons Other...

*Have others shared with you that they are concerned about the student?

Yes No

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Detailed Incident Report
Provided detailed description of incident/concern/problem. (If possible, include date, time, location, witnesses and as detailed a report as possible of what happened
*Incident
*Action Taken

Reporter Information
Do you wish to remain anonymous to the student?

Yes No

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I hereby acknowledge that the information submitted on this form is true, correct and complete to the best of my knowledge. I understand that any misrepresentation of information may result in disciplinary actions.