College Student Title IX Intake Form

Student Name

First Name

Last Name

Year in School

e.g. sophomore or professional school or PhD candidate

Student Home Address

Student Phone

(###)

###

####

Student's Personal Email

Student's School/University Email

Parent Name

Name of parent /guardian if involved

First Name

Last Name

Parent Phone

If parent is involved

(###)

###

####

Parent Email

If parent is involved

Referral Source

Adverse Parties

Witnesses

Name of College / University Attending / Program

Has a Hearing Been Scheduled or Already Held?

Dates of Any Hearings (Either Held or Scheduled)

Brief Description of What Happened