CARE Team Referral

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 NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
What is your affiliation to Briar Cliff?*
Information About the Individual(s)
Individual of Concern Type: *
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)

MonthDayYear
Date
Time of Incident (if applicable)

Hour Minutes

AM/PM Option
Referral Information
Please Rate the Urgency of this Referral*

1

2

3

4

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.*

YesNoN/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.*

YesNoN/A - Self Referral
Supporting Documents/Attachments

Optional
Cancelof
Identified Behaviors
Academic

Grades falling significantlySkipping classExcessive tardinessLow motivation/effortDoes not complete homeworkHas low reading skillsHas difficulty with math skillsHas difficulty with written languageInverts/reverses numbers/lettersPossible auditory/vision difficultiesDifficulty with peers in classroomUnable to follow directionsInability to stay on task/complete assignmentsEasily distractedFalling asleep in classRequires frequent one-on-one attentionOther
Appearance

Appearance/hygiene neglectedBloodshot eyesBruisesNeedle or burn marksWeight loss/gain (dramatic/sudden)Other
Behavior

Abusive language/profanityAlcohol/drug abuse (suspected or known)Bizarre thoughts or behaviors (i.e., hearing voices, seeing things, eating inedible objects, rocking, head banding)Cutting/scratching/hurting selfEating problems (too much or too little)Gang involvementIrritable/angry/hostileLethargic/low energyPhysically assaultive towards others/fightingRejected by peers/picked onSexually assaultive towards others/vulgarTalks about suicideThreatening/intimidating remarks/bullyingWorrying/nervousnessOther
Alarming Social Activity

Describe below.
Should be Empty:

CARE Team Referral

Your Information

Information About the Individual(s)

Referral Information

Identified Behaviors

Alarming Social Activity