Important Information Please Read

At SEO Scholars you are part of a caring community of scholars, instructors, and staff that takes its responsibility to look out for one another very seriously. To make a strong referral, please provide us with as much detail about your concern as possible. If you have any questions about this form, please email us at hssny.studentservices@seoscholars.org. Thank you for letting us know that you are concerned about a scholar and for referring them to Student Services.

IF THE SCHOLAR YOU ARE REFERRING IS A THREAT TO THEMSELVES OR OTHERS (SUICIDAL, HOMICIDAL, etc.), STOP AND DIAL 9-1-1. Please remember, these referral forms are not monitored 24/7 and therefore are not meant to be utilized for life-threatening emergencies.

*Please note that we think it is extremely important to make this as transparent a process as possible and cannot always guarantee anonymity. In making referrals to Student Services it is important to provide as detailed information as possible. Understand that the information you provide may not be considered private. While we make every effort to ensure privacy, the information provided, and where it came from may be shared with the scholar at any time throughout the case review process. If there are extenuating circumstances that make anonymity important for a safety or security reason, please make note of that in the referral and/or contact us at hssny.studentservices@seoscholars.org.
Referral Type

Scholar Information

Name of scholar you are referring.



If known, please enter the scholar's SEO ID number.
Contact Information (for person completing this form)

Please provide your first and last name.

Please provide your cell phone number (or the best number to reach you at) so that we can contact you if we have follow up questions about this referral.

Please provide your email address so that we can contact you if we have follow up questions about this referral.

Please choose how you prefer to be contacted.

Please tell us how you are connected to SEO.

General Referral Information

Please select the type of situation that you are reporting.

Please provide the approximate date that this incident occurred or enter today's date.

Please provide the approximate time that this incident occurred if applicable.

Where did this incident happen?

If applicable, please provide any additional location details (for example: in the 3rd floor lobby).



Please provide us with detailed information about your current concerns and steps you have taken to support this scholar (ex: referred scholar to another office, spoke with scholar about this concern, etc.) While some classroom disruptions can be signs of a scholar in distress, many are simply acts of ignorance or disrespect that do not indicate a higher level of concern. Common examples include arriving late to class, inappropriate comments or questions, and interrupting the lecture or discussion. By sharing your concerns with the scholar in a private setting, you'll have an opportunity to assess whether the scholar would benefit from additional support.
Additional Information

Did you consult with others? If so, please select all that apply.

Did you call the police?

Were Emergency Services called to assist individuals involved in the incident?
Upload Supporting Documents
Please attach all documents, audio, video, etc.

Upload all information supporting your referral (e.g. pictures, police reports, audio, or video files, medical documentation, assignments, screenshots, releases, etc).

eLuma (tele-therapy referral)

eLuma Referral

Emergency Fund Request

Direct funds provided to Scholars to support them and their families during hardship or emergencies.

Typically $250.00 is provided. Specific amounts may be honored on a case-by-case basis.

Funding is distributed via a VISA virtual gift card, paper check or direct deposit.



They will be sent a copy of this form.
You will be informed of the result of this request within five business days. 

Scholar Bereavement Fund

Gifts sent to scholars to show support to them and their families during times of loss or medical emergencies. Gifts typically range $50.00 - $80.00 in value. We typically gift flowers, gift baskets or a merchant gift card (i.e. Uber Eats, DoorDash, etc.) based on what we believe may resonate well with the Scholar:



They will be sent a copy of this form.
You will be informed of the result of this request within five business days.

Contact Information