CARE Team Reporting Form

Background Information

Please provide your contact information so that we may follow up with you, as needed.

Your full name:

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Your position at YC:

Your phone number:

Your email address:

Email address must be of a valid format.

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-if relevant:

Involved Parties

Please provide identifying information about the student of concern. If available to you, the Student's ID Number is the most useful identifying information. Please include contact information for other individuals who can provide information to the CARE Team about similar concerns. Please do not include yourself in this section.

Name

Select Role

Student ID Number

Phone number (if known)

Questions

PLEASE COMPLETE EACH SECTION IN AN OBJECTIVE AND FACTUAL MANNER: Please describe why this individual is being referred to the CARE Team. If applicable, Identify any implied or direct threats to self or others. Promptly report any immediate safety concerns to Campus Safety (928) 237-0420 or dial 911 before proceeding with this form.(Required) This field is required.

What type of assistance are you seeking from the CARE Team?(Required) This field is required.

Do you wish for a member of the CARE team to contact you about this concern?(Required)

Yes No No preference

This field is required.

Supporting Documentation

Please attach any supporting documents, photos or videos you may have. 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

Involved Parties

Questions

Supporting Documentation

Submission