SMSS Referral Form * indicates a required field Referring Source Information *Name *UH Affiliation: Not Selected Faculty Staff Student *Phone Number *Email Address Contact Information for Student/Staff/Faculty *Name *UH Affiliation: Not Selected Faculty Staff Student *Gender: Not Selected Female Male Trans-Man Trans-Woman Non-Binary Gender Queer Other *Email Address: PSID: *Nature of Concern: Not Selected Stalking Sexual Harassment Relationship/Dating Violence Sexual Assault Non-Consensual Touching Other *Please provide any details or information that can assist the SMSS Coordinator with supporting this individual: *Have you reported this to anyone else? Not Selected Yes, Equal Opportunity Services Yes, Provost Office or Department Chair Yes, Dean of Students Office Yes, UH Police Department Yes, CAPS Yes, Student Housing and Residential Life Yes, Other No *Does the individual know that you are making this referral? Not Selected Yes No Leave this empty: