Care Referral Form

What happens after the online referral form is submitted?

After a referral is submitted, the I-CARE Case Manager will follow-up with the referring party to confirm that their referral has been received or to gather more information. Once the referral has been processed, the I-CARE Case Manager will then reach out to the student for support and connect them with appropriate resources.

If you have questions or would like to consult with I-CARE prior to submitting an online referral, please contact the I-CARE Case Manager at, 361-825-6219.

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

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 of incident(Required):

This field is required.

Specific location:

Involved Parties

Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide.

Name

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

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

What happens after the online referral form is submitted?

Involved Parties

Questions

Supporting Documentation

Submission