CARE Team Referral Form

Presenting Issue or Concern

In the sections below, please provide as much information as you are aware of (i.e. student information, and nature of incident/concern). If information is unknown, please leave blank and move to next section.

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Referred by:

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(EX: Faculty/Staff, Student or Third Party)

Title:

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Faculty, Staff, Student, Community Member

Phone number:

Email address:

Email address must be of a valid format.

Date referred(Required):

This field is required.

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If unknown, use date report was received by you

Location of incident(Required):

This field is required.

Specific location:

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On campus office or building, residence hall, off campus location, etc.

Involved Parties

Name

ID Number

DOB (YYYY-MM-DD)

Phone number

Questions

In as much detail as possible, please explain the nature of the concern. The more information you can share, the better the team can support the student. If you have any supporting documentation (i.e. emails, papers, copies of text messages, etc.), please attach below. Please note: If this is a Title IX related matter or concern (i.e. sexual misconduct, domestic or dating violence), please be sure to make a report with the Title IX office as well.(Required) This field is required.

Based on your narrative above, please select all applicable options for need from the drop down menu below.(Required)

Mental Health/Wellness Substance Abuse Concern Suicide Ideation Food Insecurity Housing Insecurity/Emergency Housing Need Concerning or possible criminal behavior COVID-19 Other

You must make at least one selection.

Has student been referred to resources and/or provided accommodations? If yes, please explain below. This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Presenting Issue or Concern

Involved Parties

Questions

Supporting Documentation

Submission