CARE Team Referral
This form should be used for non-urgent concerns. If you are concerned about someone with suicidal thoughts or behaviors, threats to the community, or other situations requiring emergency response, please call 9-1-1.
Awknowledgement
*
I understand that this referral will be reviewed during regular business hours (Monday - Friday, 8 AM - 4:30 PM)
Your Information
Please provide your name and contact information. Enter "anonymous" in the name field if you wish to remain anonymous. Please note - the CARE Team's ability to follow up on your concern may be limited if we cannot contact you for additional information. Typically, a CARE Team member will contact the referring party to gather additional information and follow up on the situation. A Team member can also discuss any concerns you may have about privacy.
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
What is your affiliation to Briar Cliff?
*
Please Select
Faculty
Staff
Student
Family Member
Other
Information About the Individual(s)
Individual of Concern Type:
*
Please Select
Undergraduate Student
Graduate Student
Other
Name(s) of Individual(s) of Concern
If available, please provide contact information for the individual(s) of concern.
Description of Concern
*
Date of Incident (if applicable)
-
Month
-
Day
Year
Date
Time of Incident (if applicable)
Hour Minutes
AM
PM
AM/PM Option
Referral Information
Please Rate the Urgency of this Referral
*
Not Urgent
1
2
3
4
Very Urgent
5
1 is Not Urgent, 5 is Very Urgent
Does the individual of concern know you're submitting a CARE Team referral? It is helpful to share your concerns with the individual and let them know you are submitting a referral to help connect them with supportive resources.
*
Yes
No
N/A - Self Referral
Could the CARE Team let the individual know about your referral? It can be helpful to let the individual of concern know that the CARE Team received a referral on their behalf. This is always done sensitively and framed in terms of community members looking out for one another.
*
Yes
No
N/A - Self Referral
Supporting Documents/Attachments
Browse Files
Drag and drop files here
Choose a file
Optional
Cancel
of
Identified Behaviors
Academic
Grades falling significantly
Skipping class
Excessive tardiness
Low motivation/effort
Does not complete homework
Has low reading skills
Has difficulty with math skills
Has difficulty with written language
Inverts/reverses numbers/letters
Possible auditory/vision difficulties
Difficulty with peers in classroom
Unable to follow directions
Inability to stay on task/complete assignments
Easily distracted
Falling asleep in class
Requires frequent one-on-one attention
Other
Appearance
Appearance/hygiene neglected
Bloodshot eyes
Bruises
Needle or burn marks
Weight loss/gain (dramatic/sudden)
Other
Behavior
Abusive language/profanity
Alcohol/drug abuse (suspected or known)
Bizarre thoughts or behaviors (i.e., hearing voices, seeing things, eating inedible objects, rocking, head banding)
Cutting/scratching/hurting self
Eating problems (too much or too little)
Gang involvement
Irritable/angry/hostile
Lethargic/low energy
Physically assaultive towards others/fighting
Rejected by peers/picked on
Sexually assaultive towards others/vulgar
Talks about suicide
Threatening/intimidating remarks/bullying
Worrying/nervousness
Other
Alarming Social Activity
Describe below.
Submit
Should be Empty: