CARE Team Referral Form

CARE Team Referral Form

If you are concerned about the health, safety, or wellbeing of yourself, another student, faculty member, staff member or visitor, please fill out all possible fields on this form. Please call 911 to report any incident, emergency, or disaster that is severe in nature and presents an immediate or ongoing threat to campus community (e.g. act of violence, medical emergency, fire). 911 may be directly dialed from any campus phone without having to dial “9” for an outside line.
All reports will be treated with discretion. Information from this form will be shared with appropriate members of the Otero College CARE Team in order to protect the safety and health of those involved. You may remain anonymous when reporting through this form. However, it’s very helpful to have your contact information and name in case there is a need to obtain more information about the situation or clarify information. Every attempt will be made to review and address the concerns you submit on this form, but without adequate information, the college may not be able to respond as effectively. Therefore, including your contact information is strongly encouraged.
Your Contact Information
Name*

First NameLast Name
S#
e.g. S01234567
Phone Number
Please enter a valid phone number.
Email
example@example.com
I am a:*

StudentFaculty MemberStaff MemberAthletic CoachVisitor
Is this a self-referral? (Are you completing this questionnaire about you and your situation?*

YesNo
If you are completing this referral form about someone else, have your communicated your concerns directly to the individual(s)?*

YesNo
Warm handoffs increase the likelihood that the support being offered by CARE Team members will be accepted and utilized by referred students. Would you be willing to provide a warm handoff by bringing the student to the CARE Team member(s) managing their support? (If you reply “yes,” CARE Team members will reach out to you to help arrange a time for the handoff.)*

YesNo
Person of Concern's Contact Information

If you are completing this referral form about someone else, please enter their contact information below to the best of your ability and comfort. LEAVE INFORMATION BLANK IF UNKNOWN.
The person of concern is a:*

StudentFaculty MemberStaff MemberAthletic CoachVisitorOther
Person of Concern's Name

First NameLast Name
Person of Concern's S#:
e.g. S01234567
Person of Concern's Email
example@example.com
Person of Concern's Phone Number
Please enter a valid phone number.
Urgency of Concern*

Immediate - action is needed nowUrgent - action is needed as soon as possibleNormal - action is needed this week
Nature of Concern
Date of Concern

MonthDayYear
Date
Time of Concern

Hour Minutes

AM/PM Option
Location - If Applicable (e.g., McBride 113 - PSY 1001-001)
Please indicate the nature of this concern:*

Potential harm to self or othersNo harm to self or othersUnknown
Description/Narrative

Please describe your concerns in as much detail as possible. Use the person’s name, when known, rather than using pronouns (i.e., he, she, they, etc.) to identify people in your description. Indicate the specific words, phrases, interactions, or behavior that prompted this report, along with dates and times.
Support and Resources
Please indicate if any of the following areas of on-campus support may be helpful in managing this concern:*

Mental Health SupportStudent Housing ConcernsAthletic Department SupportAcademic Resources (e.g. tutoring or academic advising)Community Resource AssistanceFinancial AssistanceFood Insecurity ResourcesHousing Insecurity/Homeless ResourcesOther
If you selected "Other", please describe potential supports and resources below:
Should be Empty:

CARE Team Referral Form

Your Contact Information

Person of Concern's Contact Information

Nature of Concern

Description/Narrative

Support and Resources