Referral to Care Team

The University strongly believes in proactively meeting with students and helping them identify and follow through on resources that will support their success. You may become privy to the subtle and often unseen changes in a student’s behavior that indicate the student is stressed or struggling. Some students may come to you directly for support, advice and assistance; many may not. By making a referral, you are initiating a response from people with expertise in student services and mental health to ensure the student receives the necessary support.

Referrals will be kept confidential to the extent possible.

Report Type *

Other: Please explain *

Reporter Information

Reporter Name *

Reporter Department

Reporter Email

Email and/or phone number is required.

Reporter Phone Number

Email and/or phone number is required.

Reporter Campus Affiliation

Student Information

Student(s) Name *

Student Program *

Student Campus

Student Email

Email and/or phone number is required.

Student Phone Number

Email and/or phone number is required.

Student Other Contact Info

Incident Details

Date *

Time

Location of Incident(s)

Description of Concern *

Interventions *

Account of interventions taken, referrals made and to whom, or other relevant information

Informal Ranking of Concern *

Leave this field blank