SSC Referral Form

This form is for Mason students, staff, faculty, parents, and family members who have a student of concern within one or more our focus areas (school community, commitment to graduation, career, managing commitments, finances, well-being, effectiveness, academics, or civic engagement). A Success Coach will follow up with the student of concern within 24-48 business hours.

NOTE: If you are reporting a situation involving imminent threat of harm to self or others, please call Mason Police at 703.993.2810 or 911 first. This form is only monitored Monday through Thursday from 8:00 AM to 6:00 PM and Friday from 8:00 AM to 5:00pm.

Student's Information

First and Last Name

Student's Mason Email Address

Student's G Number (write N/A if not available)

Student's Cell Phone (write N/A if not available)

Person Submitting Referral Form

First and Last Name

Email Address

Phone Number

Please select your relationship to the student of concern

Student/Friend/Roommate
Mason Staff/Faculty
Family Member
Other