CARE Referral Form

Please provide as much detail as possible in regards to the behavior(s) that prompted your concern. Details regarding any threats of harm to self or others, or changes in behavior should also be included. The more information we have as a team, the better equipped we are to address the concern.

Please note that the checkboxes are not required fields. If you are unsure what to check, feel free to leave it blank and just type a narrative in the open text box.

Academic Concerns: Check any that apply.

Excessive absences or not attending

Poorly prepared assignments/tests

Time management, organization, studying concerns

You must make at least one selection.

Please provide a detailed description of the reason for your referral.(Required) This field is required.

Have you communicated with this student about these concerns?(Required)

Yes No Attempted to contact student - no response

This field is required.

If yes to previous question, please describe your communication with the student. This field is required.

Electronic Signature: The person completing this form should sign below.(Required) This field is required.

CARE Referral Form

Student Information

Description of Concern

Submission