Student Referral Form

The Behavioral Consultation and Advocacy Team (BCAT) responds to MCC students who are in need of guidance, support, and/or the MCC conduct process. The purpose of this referral form is to give BCAT the information needed to respond to student situations appropriately.

If you believe a student or the community is in immediate danger, please contact College Police at 531-622-2222 (ext. from campus phone: 22222). After calling police, please complete this form so BCAT can provide appropriate follow-up..

Instructions: Please completely fill out the online referral below; do not print this form. This form will be placed in a secure site and only shared as needed to respond to the student(s) involved. A copy of the completed referral will also be sent to your MCC email.

*You may also file a report “for information only” if a situation needs documented but may not require immediate intervention.

If you have questions, please contact us at or by phone: 531-622-BCAT (531-622-2228).

Julie Langholdt, Dean of Student Advocacy and Accountability
Sara Miller, Case Manager for Advocacy and Accountability

(Required fields are marked with *)

Reporting party/faculty Information: First Name*:
Last Name*:
Phone Number*:   *Format xxx-xxx-xxxx   
Email Address*:  
Date of Incident:  
Time of Incident:
Location of Incident:
Referred Student Information First Name*:
Last Name*:
Phone Number (if known):   *Format xxx-xxx-xxxx
MCC ID:  *Must be 7 digits    
Email (if known):  
Follow up Action Requested (check as many as are relevant):

You may be contacted regarding your report for additional information.

Below are categories that may be causing you to be concerned about a student or may put a student at risk of violating the Code of Student Conduct. Select all that may apply:

Was College Police called to handle the incident?: 
Have you attempted to resolve this concern with the student involved?*

Provide a detailed description of the incident or behavior that is causing you to be concerned, using language that is specific, concise, and as objective as possible. Please use direct quotes, including profanity or abusive language. Describe changes in behavior. Please forward any additional documentation to the Behavior Consultation and Advocacy Team at*

Please provide us with the names and contact information of others that may be able to provide additional information or who were witnesses to the behavior of concern.

What is your desired outcome after talking to the appropriate school officials?*