Student Care Team Referral

Background Information

Your full name:

Your relationship to student:

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This is your affillation to the student, which might include faculty, staff, peer, or family member.

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

Urgency of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location Type(Required):

This field is required.

Specific location:

Student(s) of Concern

Please provide as much information as you can (fields are not required):

Student Name

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Situation Information

Please describe your concern in detail:(Required) This field is required.

Have you notified anyone else? If yes, who? This field is required.

Do you want to be contacted by a member of the Care Team to discuss the information in this report? This field is required.

Does the student know you are submitting this report to the Care Team? This field is required.

Do you believe the student wants to be contacted by a member of the Care Team? This field is required.

Supporting Documentation

If you have any files, pictures, or screenshots to assist us, please attach them here. As a reminder, this is a secured site. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Student(s) of Concern

Situation Information

Supporting Documentation

Submission