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The Intervention Request Form provides employees an opportunity to share a concern about a students academic progress, wellness, or safety. In case of an emergency, dial 911, or call Penn State Berks Police Services at 610-396-6111. (Police pager after business hours: 610-396-4822).

Full Name of Person Reporting

Status of Person Reporting

Email Address

Complete any student information that is known:

Student Name

Student ID Number

Student Phone Number

Student Cell Number

Student Email Address

Student Address

Observed behaviors that cause concern:

Observed verbal/written statement(s) that cause concern:

Actions taken to date: (Check all that apply)

Shared observations and concerns with the student
Provided campus/community resources to student
Reported observed behaviors to:

I informed the student that I would notify the Intervention Request Form

Referred student to the following resources: (Check all that apply)
Counseling Services
Health Services
Disability Services
Learning Center




: Please Specify

Thank you for sharing your concern with us. The name of the person reporting will not be shared with the student. Receipt of notification will be provided.