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REFERRAL FORM: Cougar Care Network, Basic Needs or Early Academic Intervention


**If this is an immediate safety concern (e.g. you have a reasonable suspicion that the student is a threat to their self or others), please call University Police at (760) 750-4567, or dial 911. This form is NOT designed as an emergency response notification. Please note that referrals are not reviewed after 5:00 PM, on weekends, or during official University holidays or breaks.**


Cougar Care Network (CCN) is CSUSM’s early support initiative to improve student success, retention, and persistence by providing students with the information, resources, and support needed to ensure their personal and academic success. The goal is to support students who may be in distress or whose behavior is of concern to others before they rise to a crisis level.

Basic Needs takes a holistic approach to students' wellbeing, both inside and outside the classroom, by providing essential resources to address food, housing, transportation and financial insecurities. 

Early Academic Intervention (EAI) provides a streamlined process to refer students for early academic support who may be struggling in the following classes: GEL, GEW 101A/101B, GEO 102, UNIV, PHIL 110, Math 105/5, and Math 115. For assistance with non-EAI designated courses, please select CCN as the nature of the referral, not Early Academic Intervention.

This referral form is intended to encourage faculty and staff to refer a student who may be struggling with:
- academic,
- personal,
- financial,
- emotional difficulties and/or
- exhibiting concerning behavior

Please provide detailed information regarding the concern you are reporting. Referrals made using this form do not violate student privacy rights.

Students are typically notified of the referral source. If you have concerns about being identified, please do not complete this form and contact us at (760) 750-7627 or ccn@csusm.edu to consult on how to best support the student.

Your Information

 
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Student Information

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Primary Reason for Referral

I understand that this report will only be reviewed during normal business hours, Monday - Friday 8:00 AM to 5:00 PM, and is not monitored after hours, on weekends, or during official University holidays/closures. IF I BELIEVE THERE IS AN IMMEDIATE RISK OF HARM TO SELF (such as potential suicidal ideation) OR OTHERS, I WILL CONTACT UNIVERSITY POLICE AT (760) 750-4567 PRIOR TO SUBMITTING THIS REPORT. During business hours, I may consult with Cougar Care at (760) 750-7627 if I am concerned about the timely or emergency nature of the report.(Required)
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I am(Required)
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For EAI referrals only, I am a faculty member teaching this student in _________
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Have you addressed the concern directly with the individual?(Required)
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Does the student know they are being referred? (Students are typically notified of the referral source. If you have concerns about being identified, please do not complete this form and contact us at (760) 750-7627 or ccn@csusm.edu to consult on how to best support the student.)(Required)
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Supporting Documentation

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